Empire blue cross blue shield authorization to release information 2026

1. Click ‘Get Form’ to open the Empire Blue Cross Blue Shield Authorization to Release Information in the editor.
2. Begin by entering your personal details as they appear on your member ID card. This includes your last name, first name, middle initial, group ID number, individual ID number, social security number (optional), date of birth, daytime telephone number, street address, city, state, and zip code.
3. In Part A, authorize Empire Blue Cross and its affiliates to disclose your information by checking the appropriate box.
4. In Part B, specify who will receive your information. Ensure that this person is at least 18 years old and provide their relationship to you.
5. For Part C, select whether you want all your information disclosed or only limited information. If choosing limited information, check all applicable boxes for specific types of data.
6. Indicate any sensitive information you wish to authorize for release in the designated section of Part C.
7. In Part D, clarify the purpose of this authorization by checking the relevant box.
8. Set an expiration date for this authorization in Part E. You can choose a specific date or allow it to expire one year from the signature date.
9. Finally, read through the entire form carefully before signing in the designated area. If applicable, have your legal representative complete their section as well.

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