Authorization For Release of Confidential HIV and Related Information

By completing and returning the form below (provided by the New York State Department of Health), you can authorize us to disclose your protected health information regarding HIV to another individual or organization.

Important Instructions:

  1. Please write the following information at the top of the form:
    • Your Health Insurance Member ID Number
    • Your Date of Birth

  2. Mail or fax your completed form, with the information above, to:
    Excellus BlueCross BlueShield
    P.O. Box 21146
    Eagan, MN 55121
    FAX: (315) 671-7079

  3. Complete a separate form for each person to whom you authorize us to disclose your information.

  4. Keep a copy of your completed form for your records.

Privacy regulations require that this form be completed in order for us to disclose information to anyone other than you, including your parents if you are 12 years of age or older, and your spouse if you are married. There are some exceptions to the regulations. For example, your personal physician may receive this information from us without your written authorization.

Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. .
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