Authorization for Use of Protected Health Information
NOTE: This form is not required if you are ONLY applying for HIPAA coverage.
By signing below:
I authorize Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company, or an agent, subsidiary or affiliate that has a business associate contract with Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company, to obtain any medical records or other health history information concerning me and any family member listed on my Application from any physicians, hospitals, pharmacies, other health care providers, pharmacy benefits managers, health benefits plans, health insurers, medical or pharmacy benefit administrators, Consumer Reporting Agencies, the MIB, Inc. (MIB) (MIB Disclosure) and/or insurance support organizations. I further authorize Anthem Blue Cross or Anthem Blue Cross Life and Health Insurance Company to disclose protected health information it may collect about me to Consumer Reporting Agencies, MIB, Inc. and/or insurance support organizations for the purpose of fraud and abuse detection for this Application and for eligibility for benefits.
YOU HAVE THE RIGHT TO REQUEST HEALTH INFORMATION THAT MIB, INC. MAY HAVE ABOUT YOU AT NO EXPENSE TO YOU BY CALLING 1-866-692-6901.
I also authorize any physicians, hospitals, pharmacies, other health care providers, pharmacy benefits managers, health benefit plans, medical or pharmacy benefit administrators, Consumer Reporting Agencies, MIB, Inc., and/or insurance support organizations to furnish any medical records or health history information concerning me and any family member listed on my Application to Anthem Blue Cross and/or
Anthem Blue Cross Life and Health Insurance Company, or an agent, subsidiary or affiliate that has a business associate contract with Anthem (Blue Cross Application Section 8)
