Get Anthem Hippa Release Form To Print

Filling out the Anthem Hippa Release Form is an important step in managing your health information. This guide will provide you with clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the Anthem Hippa Release Form online.

1. Click the ‘Get Form’ button to obtain the form and open it for editing in your browser.
2. In Section A, provide the individual's information for whom the authorization is being granted. Fill in the date of birth, full name, address, social security number, member ID, and group number as indicated.
3. In Section B, indicate who can release the information by selecting 'Anthem Blue Cross and Blue Shield and its Business Associates.'
4. In Section C, specify who can receive the information. Choose a person or a company/agency, and complete the corresponding address fields.
5. Section D requires you to check the information categories you wish to authorize for release. You can also describe additional specific information needed and include any relevant dates.
6. In Section E, identify the purpose of the information release by selecting the appropriate check box.
7. Fill in the expiration date in Section F. This can either be a specific date, an event, or it will default to one year from the date you sign the form.
8. In Section G, provide the printed name and signature of the individual granting authorization, along with the date. If applicable, include signatures for parents or legal representatives, ensuring any necessary authority documentation is attached.
9. Once all sections are completed, save your changes. You can then download, print, or share the form as required.

Complete the Anthem Hippa Release Form online today to manage your health information effectively.