Medex Member Designation of an Authorized Representative An authorized representative is someone chosen by a member to assist the member with health care issues, and to whom Blue Cross Blue Shield of Massachusetts (Blue Cross) is allowed to disclose and discuss the member’s protected health information. An authorized representative is not, however, a person who has legal authority to act on behalf of a member. Use this form to designate an authorized representative to speak to Blue Cross on your behalf and to provide access to your information as shown below. The member should be the person signing this authorization and designating the release of information. If the member is a minor, a parent or legal guardian must sign. If this form is completed by a legal representative (example: a person who has legal authority to act on the member’s behalf), they must complete and submit the Blue Cross Documentation of Legal Representative Status Form prior to submitting this form to Blue Cross *Indicates a required field Member Information First Name Last Name Date of Birth Email (optional) Phone Number Street Address Apartment or Unit Number (optional) City - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Enter a three-character prefix, then numerical digits Member ID Authorized Representative Information First Name Last Name Date of Birth Professional status or relationship e.g. child, attorney, etc. - Select -SpouseSon/DaughterAttorneyFriendOther Relationship to member Relationship to member - Other Phone Number Email Address Street Address Apartment or Unit Number (optional) City - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Information That Blue Cross May Disclose By checking the box below, I grant Blue Cross permission to discuss with or disclose to my authorized representative on my behalf: All my information:This may include a diagnosis (name of illness or condition), procedure (type of treatment), claims, doctors and other health care providers, and financial information (like billing and banking). This does not include sensitive information (see below), unless explicitly approved below. This also includes appeals and grievances, claims and payment, eligibility and enrollment, pharmacy, benefits and coverage, dental, financial, billing, diagnosis and procedure, and medical records. If “all my information” is not checked above, I authorize Blue Cross to disclose only the following specific information, excluding sensitive information (unless approved below). (Check all boxes that apply). Appeals and Grievances Benefits and Coverage Billing Claims and Payment Dental Diagnosis and Procedure Eligibility and Enrollment Financial Medical Records Pharmacy Others Please specify other details. Other I approve the disclosure of the following types of sensitive information by Blue Cross (check all boxes that apply): HIV or AIDS Mental or behavioral health Alcohol and substance abuse(Member must designate specific reason for disclosure of this sensitive information) To assist with claim(s) payment (Including FSA, HRA, HSA, and Coordination of Benefits Coordination of care Assist with treatment Other Please specify a reason. Other Date Your Designation Expires One-year from the date of signature Other Date to be completed by member/legal rep; not to exceed 1 year from date of signature. Other date Member or Legal Representative Acknowledgement By checking this box, I acknowledge that I have read the contents of the form. I understand, agree, and allow Blue Cross to discuss and/or disclose my information as I have stated above. I understand that Blue Cross does not require that I sign this form in order for me to receive treatments or payments, or for enrollment or eligibility benefits. I understand I am entitled to a copy of this form and agree that a photocopy is as valid as the original. I understand this designation is valid for 1 year. I may revoke this designation at any time within the year by notifying Blue Cross. I understand that a revocation will not apply to information that was already disclosed. I understand that once information has been disclosed according to these instructions, the Health Insurance Portability and Accountability Act (HIPAA) and other privacy laws may no longer protect the information. Blue Cross may request information, now or in the future, as it deems necessary to confirm authorized representative status. data_send_successfully_to_form_api documentum_id Submit Contact Information If you do have questions, call us at 1-800-258-2226 (TTY: 711). Monday through Friday 8:00 a.m. to 6:00 p.m. ET.