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 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.

Download an electronic copy of the Blue Cross NC Member Appeal Representation Authorization Form.