Standard Authorization Form To Use or Disclose Protected Health Information (PHI) BlueCross BlueShield of Texas I - txhealthpool 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the individual’s information in Section I. Include the name, date of birth, group number, identification/subscriber number, address, social security number, city, state, ZIP code, and telephone number.
3. In Section II, provide details about the authorization and purpose. Specify the persons or organizations authorized to receive the information and their relationship to you.
4. Complete Section III by checking 'yes' or 'no' for the release of sensitive protected health information under state law. Fill out Parts A and B with specific descriptions of the information to be disclosed.
5. In Section IV, indicate when this authorization will expire and understand your right to revoke it at any time.
6. Finally, sign and date the form in Section V. If applicable, provide details for a personal representative.

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