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Member appeal representation authorization form

A federal regulation called the Health Insurance Portability and Accountability Act (HIPAA) changes the way in which health care companies and medical care providers are permitted to use and disclose information about our Members.

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has always been committed to protecting our Members’ health information, and now we are implementing additional policies and procedures to safeguard their information. Please read the Notice of Privacy Practices that explains in more detail our practices concerning Members’ protected health information.

In addition, because of the new federal regulations, we want to highlight the following important changes:

  • As described in the Notice of Privacy Practices, a Member may authorize another person to receive their protected health information.
  • Effective, April 14, 2003, we will not be permitted to give our Members’ protected health information to another person unless we have legal permission. One way they can give us permission is to sign a document called an “Authorization.” Blue Cross NC will no longer release information to another person other than the Member unless we have a signed authorization from them.
  • For your convenience, we have created an electronic Member Appeal Representation Authorization Form which you can print and give to your patient for his/her signature.

See below for some helpful tips when filling out the Member Appeal Representation Authorization Form:

  • Make sure the following fields are completed: Patient Name, Member ID and Date of Birth.
  • If your request is for a service that has not yet been performed, you can leave the Date(s) of Service field blank or enter ‘Future’.
  • Complete the Provider field with the name of the provider who will be performing/who has performed the service.
  • Complete the Regarding field with either the service being appealed, issue being appealed or authorization number (if applicable).
  • Replace ‘please enter representative’s name’ with the name of the person that you are allowing to appeal on your behalf.
  • You must sign and date the form.
  • Mail the completed form and appeal request to: Blue Cross NC, P.O. Box 30055, Durham, NC 27702-3005.

View an electronic copy of the Blue Cross NC Member Appeal Representation Authorization Form (PDF).

View an electronic copy of the Blue Cross NC Member Appeal Representation Authorization Form in Spanish (PDF).