Excellus BCBS Letter of Authorization - Release of Coverage Information

Sep 15, 2026

Uploaded by Mary Man

Authorization letter template for submitting on group letterhead to Excellus BCBS, addressed to Broker Administration. It grants the named broker agency permission to receive and release information related to the company’s coverage. The letter clarifies that the broker is not authorized to act on the company’s behalf for benefit updates or changes and receives no compensation. Authorization remains valid for six months from the specified date unless revoked in writing.

LanguageEnglish

CategoryLetters

FormatPDF

Pages1

AccessFree to download

Letter of Authorization

Recipient and Address

Authorized Broker Agency Details

Authorization Scope and Limits

Effective Period and Revocation

Signature and Officer Information

FAQs

Who is the letter addressed to and what information must be included?

The letter is addressed to Excellus BCBS, Attn: Broker Administration, with the full address provided. It requires the broker agency name and address details as well as the company officer signature information.

What does this authorization allow the broker agency to do?

It authorizes Excellus Health Plan to release information related to the company’s coverage to the broker agency listed in the letter.

How long is the authorization valid and can it be revoked?

The authorization remains in effect for six months from the listed effective date. It can be revoked if the company notifies Excellus BlueCross BlueShield in writing to the contrary.

Sep 15, 2026

Uploaded by Mary Man