What Form Should I Use?

At Blue Cross Blue Shield of Arizona (BCBSAZ), we are very protective of the personal health information of our members. We can share your information with others when you provide us with permission to do so, when it is permitted by law and as described in our Notice of Privacy Practices. Our Notice of Privacy Practices provides more detail regarding how we may use or disclose your information.

To share your information with another person or company, you can fill out a Confidential Information Release Form. This form is available on the BCBSAZ website here. On this form, you can tell us what information we can share, who we can give information to, and when we are to stop sharing.

It is up to you to decide how much (or how little) information you want us to share. Use the checkboxes in the “Tell Us What Records We Can Share” section of the form to select what we can share.

This form also has an optional section you can complete that will allow the person you designate to update your address on file or update the bank draft information we have on file for you.

With this form on file, we can then answer that person’s questions or give them information about your coverage or claims, based on what you have authorized on the form.

Many of the Confidential Information Release Forms we receive are incomplete. When this happens, we will return the form to you and ask you to fill in any missing information. We will not be able to share your information with the person indicated until we have a complete, valid form.

We recommend that you carefully review the Confidential Information Release Form before you send it in to make sure it is complete. The “Change My Records” section of the form is optional, but all the remaining sections should be filled out.

One of the most common things missing from the form is when the form expires. Please be sure to indicate in the “Tell Us When to Stop Sharing Your Information” section of the form when your permission ends. You can select either “90 days after the health plan ends,” which keeps the authorization open indefinitely while your policy is in effect with us, or you can write in a specific date you want the authorization to end.

If you would like us to share any HIV-related information with someone, we have a special form that must be filled out. It is located here. Please be aware that this form is valid for no more than 180 days, based on the requirements of Arizona law.

You can cancel a Confidential Information Release Form at any time. Just send the cancellation in writing to BCBSAZ, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-3466. Tell us the date you would like the cancellation to take effect, and include your BCBSAZ member ID number.

A Confidential Information Release Form does not allow the person you indicate to change or cancel your insurance policy, or to submit health care appeals or grievances on your behalf. To change or cancel a policy, apply for coverage or otherwise manage your policy, we need a Power of Attorney.  

Please be aware that there are different types of Powers of Attorney, and they can authorize different things.  A Health Care Power of Attorney will allow us to share your health information with the person indicated on the form, and also let that person manage your health care matters. A Durable Power of Attorney or Financial Power of Attorney typically doesn’t cover health care matters, but it may.

The following chart may be helpful in determining which form to send to us:

ACTION	Confidential Information Release Form	Health Care Power of Attorney	Durable Power of Attorney or Financial Power of Attorney	Authorized Representative Designation Form	Appointment of Representative Form (Medicare Advantage)
Allow BCBSAZ to share my healthcare information and claims with another person/entity	X	X			X
Allow someone to receive paper copies of my healthcare information, explanations of benefits or claims	X	X			Yes, if related to an  appeal or grievance
Allow BCBSAZ to share my healthcare information AND also authorize another to act on my behalf		X			X
Allow someone to sign me up for coverage			X
Allow someone to change which health care plan I'm enrolled in, change the deductible or change the date my coverage starts/stops			X
Allow someone to cancel my policy			X
Allow someone to change the address that BCBSAZ has on file	Yes, if the address change part of the form is completed	X	X
Allow someone to submit a health care appeal for me		X	X	X	X
Allow someone to file insurance claims for me		X	X	X

Please note that the above chart is very general. Power of Attorney documents vary, so we need to review the individual documents to see what they authorize.

If you have a Power of Attorney that you want us to recognize, please send it to our Privacy Office. You can mail it to: Blue Cross Blue Shield of Arizona, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-9985; you can fax it to (602) 544-5661 or you can email it to privacy@azblue.com.

Please be sure to include a complete copy of the form. We will review it to see what powers you have given to the person indicated on the form.

If the Power of Attorney is acceptable, we will put it on file allowing the person designated on the form to manage your policy and receive your information.

If the Power of Attorney does not appear to be acceptable or is incomplete, we will send you a letter asking for a valid form or all pages of the document.  If the Power of Attorney only covers financial matters, we will also include a Confidential Information Release form with our letter to you.

A person who has been given “guardianship” of another person is generally able to manage all of the person’s health matters. A guardianship will usually have powers similar to a Health Care Power of Attorney.

“Conservatorship” usually covers managing a person’s financial affairs. They are often similar to a Financial Power of Attorney.

If you have been granted guardianship or conservatorship over another person, please submit a copy of the letters of appointment of guardian or conservator to BCBSAZ. You can mail the papers to: Blue Cross Blue Shield of Arizona, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-9985; you can fax them to (602) 544-5661 or you can email them to privacy@azblue.com.

With these papers on file, we will then be able to work with the guardian/conservator.

To allow another person to submit an appeal or grievance for you, we need an Appointment of Representative form or a Power of Attorney. The Appointment of Representative form cannot list multiple people to act as your representatives, but should list one person. The form must be fully completed to be acceptable. It must be signed, dated, and the person you name as your representative must also sign the Acceptance of Appointment part of the form and indicate if they are waiving any fees due for representing you.

An Appointment of Representative form will also allow us to share your information with the representative you name in the form.

All correspondence related to your appeal or grievance will be sent to the appointed representative.

If your coverage is not Medicare Advantage and you want to name another person or provider to submit appeals or grievances for you, we need an Authorized Representative Designation Form naming this other person or provider. If you also want us to share information with the person you name, we will also need a Confidential Information Release Form, as discussed above. A Power of Attorney document is also usually acceptable, preferably one that covers health care.

A Confidential Information Release Form by itself is not sufficient for the person indicated to submit an appeal or grievance for you.

Our prescription drug plans have different forms you need to fill out for appeals. Call the customer service number on the back of your member ID card for more information.

We sometimes receive requests from attorneys or law firms stating that they represent you. We will not share your information with your attorney without your permission.

We require attorneys to provide a signed authorization from you giving us permission to work or talk with them. This can be either the BCBSAZ Confidential Information Release Form, or it can be a similar form from the attorney that meets the federal privacy rule’s requirements.

Under federal privacy rules, parents are authorized to receive health information about their minor children. Arizona state law ARS §25-403.06 specifically requires us to provide equal access to both parents regarding their minor children’s health information.

This information sharing applies even if the parents are divorced or the parent is not covered by the policy. We may ask for documentation to confirm the parental relationship to the child.

If you do not want us to share information regarding your minor child with his or her parent, we need legal documentation such as a court order that would support such a restriction.

When a person has passed away, we need to find out who is managing the person’s estate (the executor). A Power of Attorney typically ends upon a person’s death, so that document no longer is in effect.

Our process is to send a letter to the person who we believe is the executor of the estate requesting a copy of the death certificate.

If the person managing the estate only needs to get access to the deceased person’s information, we require the death certificate. An original is not needed.

If we owe any money to the estate such as premium refunds or claims payments for out-of-network providers, we also require one of the following:

• Letters of Personal Representative from a court.
• A certificate of trust or pages of the trust that show:
• who created the trust
• the name and address of any beneficiary
• the name and address of any trustee and successor trustee, and
• the signature page.
• If probate is not needed and the estate is worth less than $75,000, we have an affidavit that can be filled out indicating there is no other person that represents the estate.

If you have any privacy-related questions, please call us at 602-864-2255 or if out of state at 1-800-232-2345, extension 2255. You may also email us at privacy@azblue.com.