[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288398-105":53,"doc-detail-288398-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","ers-hipaa-standard-authorization-form-instructions-for-completing","ERS-HIPAA Standard Authorization Form - Instructions for Completing","","Instructions guide the user to complete an ERS-HIPAA Standard Authorization Form used to authorize Blue Cross Blue Shield of Texas to disclose protected health information (PHI) to a specified person or entity. The user is told to fill out all required fields and that authorization is voluntary. The form covers identifying the individual, naming the authorized recipient and purpose, and selecting the specific PHI categories and any sensitive protected health information under state law. It also notes that psychotherapy notes cannot be disclosed through this authorization.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ers-hipaa-standard-authorization-form-instructions-for-completing/288398/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ers-hipaa-standard-authorization-form-instructions-for-completing/288398.png","ImageObject",442,249,{"name":88,"@type":89},"Chloe Bennett","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of this authorization form?","Question",{"text":108,"@type":109},"It authorizes Blue Cross Blue Shield of Texas to disclose the individual’s protected health information (PHI) to a specific person or entity for a stated purpose.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Is filling out the form required, and is consent voluntary?",{"text":113,"@type":109},"All fields must be completed, and the individual’s use of the authorization form is always voluntary.",{"name":115,"@type":106,"acceptedAnswer":116},"What information can’t be disclosed using this authorization?",{"text":117,"@type":109},"This authorization cannot be used to disclose Psychotherapy Notes.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288398,1790062304,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},962084925782,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Instructions for Completing Standard Authorization Form  \nTo Complete Form go to Page 4 of 5  \nUse this form to authorize Blue Cross Blue Shield of Texas to disclose your protected health information (PHI) to a specific person or entity. You may follow the instructions we provided below or you may call the Customer Service number listed on the back of your Membership Identification card for assistance in completing the form. You must complete all the fields on this form.  \nPlease remember:  \n• One authorization form can be used for a range of and/or multiple services or providers.  \n• Authorization forms can be completed claim by claim, procedure by procedure, or for services within specified timeframes.  \n• The individual’s use of the authorization form is always voluntary.  \nI. Individual (Name and information of person whose protected health information is being disclosed):  \n\n| Name |  | Date ofBirth |\n| --- | --- | --- |\n| Group \\# | Identification/Subscriber \\# | Social Security Number |\n\nAddress City State ZIP  \nArea Code & Telephone Number  \nAll of the information in Section I pertains to the individual for whom the authorization is being requested. The individual may be the subscriber, his or her spouse, a dependent or any other individual covered or applying for coverage under the subscriber’s membership. All fields in this section are required. In this example, Jane Doe is the individual for whom the authorization is being requested.  \nII. Authorization and Purpose:  \nI request and authorize Blue Cross and Blue Shield of Texas to disclose my protected health information as described below. I understand that if the person/organization authorized to receive and use the information is not a health plan or health care provider, the disclosed information may no longer be protected by federal privacy regulations.  \nPersons/Organizations authorized to receive your information Relationship Purpose  \nAddress City State ZIP  \nSection II identifies the person/entity that will be receiving the PHI about the individual identified in Section I. An individual could authorize disclosure of his or her PHI to a close friend, a broker, an attorney, or a specific member of his or her employer’s benefits staff. The individual may also authorize disclosure to an organization. Include the information identifying the organization’s job titles to receive the PHI (e.g., Benefits Representatives, Human Resources Department, XYZ Insurance Agency, etc.) . In this example, Jane Doe has identified her daughter, Suzy Smith as the person who is authorized to receive her information.  \nRev. 05/17/24-HCSC Privacy Office Page 1 of 5 SAF-TX  \nBlue Cross and Blue Shield, A Division of Health Care Service Corporation, a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue Shield Association  \nIII. Specific Description of Information to be Used or Disclosed (Please Complete Parts A and B in this Section)  \nThis Authorization CANNOT be used to disclose Psychotherapy Notes.  \nSection III will assist in determining what PHI the individual identified in Section I allows the receiving person/entity identified in Section II to receive. This section has two parts, both of which must be completed.  \nA. Release of Sensitive Protected Health Information Under State Law  \nYou must check “yes” or “no” if you authorize the release of medical information, test results, records or communications specific to  \n(note: “yes” means this information is included in the categories you designate in Part B below):  \n• Human Immunodeficiency Virus (HIV) or HIV/Acquired Immune Deficiency Syndrome  \n• Sexually transmitted or “communicable” diseases (includes hepatitis, as well as venereal diseases);  \n• Drug, alcohol or substance abuse;  \n• Mental health or developmental disabilities (including mental retardation or similar disabilities, for example, those attributable to cerebral palsy, autism or neurological dysfunctions); and  \n• Genetic testing.  \nYes","cbCaibduhX9L1Unf","https://ap.wps.com/l/cbCaibduhX9L1Unf","pdf",1764527,8,"English","# Instructions for Completing Standard Authorization Form\n## Use of the Authorization Form\n## Section I: Individual Information\n## Section II: Authorization and Purpose\n## Section III: Specific Description of Information to Be Used or Disclosed\n### Part A: Sensitive Protected Health Information Under State Law\n### Part B: Release of Protected Health Information Categories","[{\"question\":\"What is the purpose of this authorization form?\",\"answer\":\"It authorizes Blue Cross Blue Shield of Texas to disclose the individual’s protected health information (PHI) to a specific person or entity for a stated purpose.\"},{\"question\":\"Is filling out the form required, and is consent voluntary?\",\"answer\":\"All fields must be completed, and the individual’s use of the authorization form is always voluntary.\"},{\"question\":\"What information can’t be disclosed using this authorization?\",\"answer\":\"This authorization cannot be used to disclose Psychotherapy Notes.\"}]","ERS-HIPAA Standard Authorization Form - Instructions for Completing | PDF",1789633445]