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MEMBER AUTHORIZATION This form is to be filled out by a member ... 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin with Part A: MEMBER INFORMATION. Fill in your last name, first name, street address, daytime phone number, city, cell phone number, subscriber number from your ID card, middle initial, date of birth, state, zip code, and group number.
- Proceed to Part B: PERSON OR COMPANY WHO WILL RECEIVE INFORMATION. Check the applicable boxes for individuals or companies authorized to receive your information and provide their names where required.
- In Part C: INFORMATION THAT CAN BE RELEASED, select either 'All of my information' or 'Only limited information' and check the specific types of information you wish to release.
- Complete Part D: PURPOSE OF THIS APPROVAL by indicating the reason for sharing your information.
- Fill out Part E: DATE YOUR APPROVAL EXPIRES by selecting an expiration option.
- In Part F: FORM OF INFORMATION REQUEST, choose how you would like the information transmitted (paper copies, fax, digital copies, or email).
- Finally, review and sign in Part G: REVIEW AND APPROVAL. Ensure all sections are completed accurately before submitting.
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Please fill out the form below to request verification and authorization before sending any sensitive information to third parties. Restricted InformationRead more
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION. Fax: 801-646-7210 / Phone: 877-358-8797 801-646-7210
I submit this form voluntarily to document my wishes regarding the use and/or disclosure of the information described below. The following is a specificRead more