Get Conditioned Authorization Form - Instructions - Blue Cross Blue ...

Completing the Conditioned Authorization Form for Blue Cross and Blue Shield of Georgia is an important step in authorizing the use and disclosure of your protected health information. This guide will provide clear and supportive instructions to help you fill out the form accurately and efficiently.

Follow the steps to successfully complete the Conditioned Authorization Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. For each individual over the age of 18, clearly print the full name of the individual (applicant, spouse, or dependents) on the designated line located on the left-hand side of the form.
3. After entering each individual's name, ensure that they sign their name in the corresponding space on the right-hand side of the form. The signature should match the one used on their enrollment application.
4. If there are more dependents than the available spaces, make a copy of the original enrollment form prior to any signatures and repeat the process for each additional dependent. Remember to label the copies in the upper right-hand corner as Page 1 of 2, Page 2 of 2, etc.
5. In the provided space, date the form or each page of the form to indicate when it was completed.
6. If a legal representative is completing the form for someone else, they must sign and date the authorization in the specified block and attach necessary documentation that verifies their legal status (like Health Care Power of Attorney).
7. Once you have completed the form, make a copy for your records. Include the finalized authorization form in your enrollment package or provide it to your Broker/Agent or the BCBSGA Associate assisting you with enrollment.

Complete your Conditioned Authorization Form online today.