Get Authorization Form-excellus B-1565.doc

Filling out the Authorization Form-Excellus B-1565 online is a straightforward process that allows you to share your protected health information securely. This guide provides you with clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Authorization Form-Excellus B-1565 online.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. In the first section, tell us who you are by providing your name, address, city, state, zip code, member ID number, and birth date.
3. In the second section, indicate why you would like Excellus BlueCross BlueShield to share your information. You can choose to respond to all requests for confidential information or specify particular requests.
4. In the third section, identify the specific types of information you would like to share. Check all categories that apply, such as claim information, membership information, benefit information, or medical records.
5. In the fourth section, list the names and addresses of the individuals or organizations with whom you wish to share your information.
6. In the fifth section, specify the time period during which you would like this information to be shared. You can choose until completion of outlined activities, until you cancel authorization, or specify a date range.
7. In the final section, please provide your printed name, signature, and date to give your consent for sharing your protected health information. If a personal representative is signing, their information and authority must also be included.

Complete your documents online to ensure accurate and efficient processing.