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.

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

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.

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) 864-3152 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 it to (602) 864-3152 or you can email it to privacy@azblue.com.

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

To allow another person or company to submit an appeal or grievance for you, we need the following:

1. A Confidential Information Release Form and an Authorized Representative Designation Form or
2. A Power of Attorney document, preferably one that specifically 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. We also need a separate form called an Authorized Representative Designation Form that you can get here.

A Power of Attorney document will usually also work to allow the person indicated on the form to submit an appeal or grievance for you.

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.

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.