Get Hipaa Member Authorization Form - Anthem

Filling out the HIPAA Member Authorization Form - Anthem is essential for allowing the disclosure of your personal health information. This guide will help you navigate each section of the form, ensuring accurate and complete submission.

Follow the steps to fill out the form online efficiently.

1. Press the 'Get Form' button to access the HIPAA Member Authorization Form.
2. Complete the personal information section by entering your last name, first name, middle initial, group ID number, individual ID number, date of birth, and daytime telephone number. Ensure all information matches what is on your member ID card.
3. Fill in your street address, city, state, and zip code to provide your current residence details.
4. In Part A, authorize individuals or parties who can disclose your information. Specify the name of the operating company and its affiliates you wish to include.
5. In Part B, identify the person or type of individuals authorized to receive your information. Ensure the individual receiving the information is at least 18 years of age.
6. In Part C, indicate which specific information you allow to be disclosed by checking the appropriate boxes. Choose between disclosing all information or limited information based on your preferences.
7. In the section regarding sensitive information, specify any types of information you do not wish to authorize for release by checking the relevant boxes.
8. Complete Part D by identifying the purpose of the authorization. Select an option that fits your reason for disclosure.
9. In Part E, set an expiration date for the authorization. Choose from the available options based on your preferences for the duration of the authorization.
10. Review the contents of the authorization form to ensure that you understand and agree with the use and disclosure of your information as specified.
11. Sign and date the form at the designated section. If applicable, fill in the information for a designated legal representative or guardian, ensuring to attach any required documentation.
12. Save your changes, then download, print, or share the completed form as necessary.

Complete your HIPAA Member Authorization Form - Anthem online today to ensure your health information is managed according to your wishes.