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Completion guidance covers required member details, Section I and Section II instructions, definition of psychotherapy notes, expiration and revocation, and signature and return requirements.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/member-authorization-form-release-information/283891/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/member-authorization-form-release-information/283891.png","ImageObject",442,249,{"name":42,"@type":43},"Ben ","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",18,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must sign the member authorization form to release information?","Question",{"text":63,"@type":64},"The form must be signed by the member or the member’s personal representative. The signature also requires printing the name and dating the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"When is Section II required on the form?",{"text":68,"@type":64},"Section II is completed only if the information to be used or disclosed includes psychotherapy notes or if the disclosure involves HIV, mental health, or substance abuse information.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid, and how can it be revoked?",{"text":72,"@type":64},"Authorization must include expiration information to be valid. If no expiration box is checked, it expires 60 months after termination of enrollment. To revoke, contact the Customer Service number on the member’s ID card.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283891,1789971921,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":82,"data":127},{"doc_id":79,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":26},2336478951081,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Member authorization form to release information  \nDear member,  \nThe enclosed form is used to obtain authorization from the member whose information will be released , or the member’s personal representative , to disclose the member’s information to an individual or organization not otherwise authorized to receive this information.  \nThis form is also used to receive member authorization to use or disclose a member’s psychotherapy notes or to disclose member information related to HIV, mental health , or substance abuse. To authorize release of these types of information, they must be indicated in the enclosed form in Section II.  \nCORRESPONDENCE UNIT • CAPITAL BLUE CROSS • PO BOX 779519 • HARRISBURG, PA 17177-9519  \n[CapitalBlueCross.com](CapitalBlueCross.com)  \nFAX: 717.651.8731  \nHealthcare benefit programs issued or administered by Capital Blue Cross and/or its subsidiaries, Capital Advantage Insurance Company®, Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the Blue Cross Blue Shield Association. Communications issued by Capital Blue Cross in its capacity as administrator of programs and provider relations for all companies.  \nPO-9 (03/31/23)  \n\n| Directions for completing the member authorization form to release information | | |\n| --- | --- | --- |\n| This form is used to obtain authorization from the member or the member’s personal representative to disclose the member’s information to an individual or organization not otherwise authorized to receive this information. This form is also used to receive member authorization to use or disclose a member’s psychotherapy notes or to disclose member information related to HIV, mental health, or substance abuse. This form may only be signed by the member or the member’s “personal representative”(see description of personal representative below) .\u003Cbr>PLEASE PRINT\u003Cbr>Member information: Complete all information requested in this section for the member whose information will be released.\u003Cbr>Important: Name, address, ID number, and date of birth are required.\u003Cbr>• ID number: List the ID number shown on the front of the member’s Capital Blue Cross ID card. If the member has coverage with Capital Blue Cross under more than one ID number, a separate Member Authorization Form must be completed for each ID number where an authorization is applicable.\u003Cbr>Authorization: There are two sections here.\u003Cbr>Section I: The first section must always be completed. You must identify the individual(s) or organization(s) to receive the information. Describe the information as specifically as possible. If more space is needed to describe the information, describe on the back of the form. Next, describe why this information is being disclosed or check “This information is being disclosed at the request of the member (or the member’s personal representative) .” If no purpose of disclosure is given, Capital Blue Cross will assume that this information is being disclosed at the request of the member (or member’s personal representative) .\u003Cbr>Section II: The second section is to be completed only if the information to be used or disclosed includes psychotherapy notes, or if the disclosure involves HIV, mental health, or substance abuse information.\u003Cbr>If this authorization is being used for psychotherapy notes, it can only be used for that specific purpose and no other.\u003Cbr>Psychotherapy notes are defined in the Health Insurance Portability and Accountability (HIPAA) Privacy Rule as:\u003Cbr>Notes made by a mental health professional that document or analyze the contents of conversations during counseling sessions, which are kept separate from the rest ofthe member’s medical record, and exclude medication, prescription, monitoring, counseling session start and stop times, treatment modalities and frequencies, clinical test results, diagnosis, functional status, treatment plan, symptoms, prognosis, or progress summary.\u003Cbr>Expiration and revocation: Expiration inf","cbCaie7aNx46SxZe","https://ap.wps.com/l/cbCaie7aNx46SxZe","pdf",216684,"English","# Directions for completing the member authorization form to release information\n## Member information\n## Authorization (Section I and Section II)\n## Expiration and revocation\n## Personal representative information\n## Signature/Date and return instructions","[{\"question\":\"Who must sign the member authorization form to release information?\",\"answer\":\"The form must be signed by the member or the member’s personal representative. The signature also requires printing the name and dating the form.\"},{\"question\":\"When is Section II required on the form?\",\"answer\":\"Section II is completed only if the information to be used or disclosed includes psychotherapy notes or if the disclosure involves HIV, mental health, or substance abuse information.\"},{\"question\":\"How long is the authorization valid, and how can it be revoked?\",\"answer\":\"Authorization must include expiration information to be valid. If no expiration box is checked, it expires 60 months after termination of enrollment. To revoke, contact the Customer Service number on the member’s ID card.\"}]","Member Authorization Form - Release Information | PDF",1789621514]