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  1. Member information
  2. Authorized Users
  3. Release Information
  4. Purpose and Duration
  5. Review and Approval

Part A: Member information

Date of Birth should not be more than Current Date.

Part B: Person or company who will receive this information

The following people or companies have the right to receive my information. (They must be 18 years of age or older). Please enter first and last name. By entering first/last name below that person may receive my information

Any one of the field should be entered

Part C: Information that can be released

I allow the following information to be used or released by Wellpoint on my behalf:

I also approve the release of the following types of sensitive information by Wellpoint (check all boxes that apply to you):

2. Unless I specify otherwise on this form, I intend this disclosure to include all substance use disorder records maintained by Wellpoint about me. I understand that my substance use disorder records are protected under Federal and State confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise provided for in the laws and regulations. Ialso understand that I may revoke (orcancel) this approval at any time, or as described in Part E. I understand that Icannot cancel this approval when this form has already been used to disclose information.

3.Reproductive health includes, but it not limited to, both male and female infertility, maternity, pregnancy loss, miscarriage, family planning, birth control, both elective and spontaneous abortion, and any other related care or services.

Part D: Purpose of this approval — Check only one box

Part E: Date your approval expires — Check only one box

If this document was not already withdrawn, this approval will end on the earliest of the following dates:

Part F: Review and approval

I have read the contents of this form. I understand, agree, and allow Wellpoint to the use and release of my information as I have stated above or as required by applicable law. I also understand that signing this form is of my own free will. I understand that Wellpoint does not require that I sign this form in order for me to receive treatment or payment, or for enrollment or being eligible for benefits.

I have the right to withdraw this approval at any time by giving written notice of my withdrawal to Wellpoint. I understand that my withdrawing this approval will not affect any action taken before I do so. I also understand that information that’s released may be given out by the person or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this form.

Designated Legal Representative/Guardian — Complete this section only if you have documentation supporting Legal Representation.

If this form is signed by someone other than the member or parent, such as a personal representative, legal representative or guardian on behalf of the member, please submit the following:

  • A copy of a health care, general or Durable Power of Attorney.

       OR

  • A court order or other documentation that shows custody or other legal documentation showing the authority of the legal representative to act on the member’s behalf.
  • .

Please complete the following

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