Loading
Get Excellus B-1565 2016-2026
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Excellus B-1565 online
Filling out the Excellus B-1565 authorization form is an important step in managing your protected health information. This guide provides a detailed walkthrough to help you complete the form accurately and efficiently.
Follow the steps to complete your Excellus B-1565 authorization form.
- Press the ‘Get Form’ button to access and open the form in a document editor.
- Begin by filling out Part A with your member information. Provide your last name, first name, middle initial, date of birth, and identification number as shown on your ID card. Also, include your current address, city, state, and ZIP code.
- Proceed to Part B to specify the person or organization with whom your information will be shared. Write the name and address of each person or organization clearly.
- In Part C, indicate the reason for disclosure. You can select ‘Any information requested’, ‘At the request of the individual’, or specify another reason. If you want to limit the information to a particular condition or date range, provide the requested details.
- Fill out Part D to specify what type of health information can be shared. Check all the relevant boxes, including enrollment, claim, benefit, clinical records, and any specific conditions. Note, skip this part if you selected the psychotherapy notes in Part A.
- In Part E, read the acknowledgement regarding your rights and the implications of the authorization. Sign and date the form where indicated. If you are filling this out as a personal representative, provide your name, signature, and description of authority.
- Once you have completed all sections, ensure all information is accurate and sign the bottom of the form. You can then save the changes, download, print, or share the form as needed.
Complete and submit your Excellus B-1565 authorization form online today.
Excellus B-1565 is owned by Excellus Health Plan, Inc., which is part of the larger BlueCross BlueShield Association. This ownership allows Excellus to provide consistent and reliable health insurance services while operating independently in its designated regions. For questions about specific ownership structures or corporate details, visiting the Excellus corporate website is advisable for the latest information.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.