Excellus authorization to print out 2007 form-2026

1. Click ‘Get Form’ to open the excellus authorization to print out 2007 form in the editor.
2. In Step 1, enter the member's name, address, city, state, zip code, member ID number(s), and birth date. Ensure all details are accurate for proper identification.
3. Move to Step 2 where you will indicate the reasons for sharing your information. Check the appropriate boxes for conditions you wish to include in this authorization.
4. In Step 3, specify the exact protected health information you want shared by checking relevant options such as claim information or medical records.
5. Proceed to Step 4 and list the names or organizations with whom you want your information shared. Remember that all individuals must have the same access level.
6. In Step 5, indicate the time period during which you would like your information shared. Choose from available options or specify dates.
7. Finally, in Step 6, print your name, sign, and date the form to authorize Excellus Health Plan to share your protected health information.

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