Caring for your loved one comes with a multitude of responsibilities. You’ll likely encounter a variety of documents and forms that require your loved one’s signature. One form your loved one will need to fill out and sign each year from Blue Cross is the Authorization for Disclosure of Health Information (ADHI). This form must be completed annually, and it’s valid from the date of signature until the following year at that time.
The form should be completed in order for Blue Cross to release a person’s information to another person or entity. If your loved one is able to sign the form, they can do so themselves. If not, the form can also be signed by the personal representative of the person whose information will be released, such as a power of attorney, conservator or executor.
It’s a good idea to keep this signed form on file with Blue Cross in case of an emergency situation in which your loved one is unable to sign it. You can find and download the ADHI form here. You can also call the number on the back of your member ID card to request a form by mail.
HOW TO FILL OUT THE FORM
Remember, it’s each member’s own responsibility to fill out the Authorization for Disclosure of Health Information each year. Here’s how to do it:
Section 1:
• Fill in the name, address, member identification and date of birth of the person whose information will be disclosed.
• Provide the date range of records to be disclosed. The “From” and “To” areas must be entered as dates (mmddyyyy). An actual date must be entered in the “From” and “To” fields.
Sections 2 and 3:
• Check the boxes to identify the type(s) of information you want us to disclose.
• You must enter the purpose for which you want the information disclosed.
Section 4:
• Fill in the name and address of the Individual, Organization, or Provider.
Section 5:
This form must be completed and signed by one of the following:
• The person whose information will be released.
• The parent or legal guardian of a minor whose information will be released except as noted above.
• The personal representative of the person whose information will be released.