Excellus b1565 form 2026

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The document outlines the authorization process for sharing protected health information (PHI) in compliance with HIPAA regulations by a nonprofit independent licensee of the BlueCross BlueShield Association. It details the conditions under which health plans can share PHI, parental access to children's health information, and specific exceptions for sensitive information. The document includes a form for members to authorize the sharing of their PHI, specifying what information can be disclosed and to whom.

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Click ‘Get Form’ to open the excellus b1565 form in the editor.
Begin by filling out Part A with your personal information, including your last name, first name, middle initial, date of birth, identification number, and current address.
In Part B, list the names and addresses of individuals or organizations you authorize to access your health information.
Move to Part C to specify the reason for disclosure. You can select options such as 'Any information requested' or provide a specific reason.
In Part D, check all applicable boxes regarding the types of information you wish to share. Be mindful that if psychotherapy notes are checked at the top, this section should be skipped.
Finally, read through Part E carefully. Sign and date the form to acknowledge your understanding and authorization.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (216 Votes)
2007	4.3 Satisfied (43 Votes)

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