Instructions for the Individual and Psychotherapy Notes

Document Sample
Instructions for the Individual and Psychotherapy Notes Powered By Docstoc
					Instructions for the Individual and Psychotherapy Notes
Authorization Forms


Purpose     To assist Anthem Blue Cross and Blue Shield members in completing the
            Individual and Psychotherapy Notes Authorization Forms.

            The applicable authorization form must be completed in its entirety. Anthem
            members are required to complete two separate authorization forms if they
            would like all protected health information and psychotherapy notes to be
            released. Members may submit forms by mail or fax.

            Failure to complete the appropriate forms correctly will result in the forms
            being returned to the member for correction and resubmission, which will
            cause a delay in processing the authorization.


Section A   Information About the Individual Providing the Authorization

                      Field                                                      Member’s Task
            Name                                               Enter your full legal name.
                                                               Note: Only enter one name per form
            Address                                            Enter your complete mailing address.
            Date of Birth                                      Enter your date of birth
                                                               (MM/DD/YYYY)
            Social Security                                    Enter your Social Security number
            Number                                             (XXX-XX-XXXX)
            Member ID Card                                     Enter the ID number on your health plan ID card.
            Number                                             (include ALL letters and numbers)
            Group Number on ID                                 Enter the group number on your health plan ID
            Card                                               card.
                                                               (include ALL letters and numbers)


Section B   Person/Company Authorized to Release the Information? This field is already
            populated on the form, and no information is needed from you.

                                                                                                                                   Continued on next page
                                        An independent licensee of the Blue Cross and Blue Shield Association.
                        Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc.
                                             ® Registered marks Blue Cross and Blue Shield Association.
Instructions for the Individual and Psychotherapy Notes
Authorization Forms, Continued


Section C   Person/Company/Agency/Facility Authorized to Receive the Information
            (Select only one.)

                      Field                                                      Member’s Task
            Name                                               Indicate the person(s) authorized to receive the
                                                               information.
                                                               Note: You may list more than one individual.
            Address                                            Enter the complete mailing address of the
                                                               authorized individual(s).
            Company                                            Indicate the company, agency or authorized to
                                                               receive the information. Note: You may list more
                                                               than one company, agency and/or facility. If you
                                                               list a company, agency and/or facility, you DO
                                                               NOT have to list a contact.
            Address                                            Enter the complete mailing address of the
                                                               authorized company, agency or facility.


Section D   Information the Individual is Authorizing to be Released
            IMPORTANT! Section D is different on the two forms.

            Individual Authorization Form

                 Field                                             Member’s Task
            Check Boxes                       Check all boxes that apply to the types of information
                                              you are authorizing for release.
            Dates of                          If you are authorizing the release of information from a
            Information                       specific date or date range, enter those dates; otherwise
                                              leave blank.

                                                                                         OR

            Psychotherapy Authorization Form

                  Field                                            Member’s Task
            Dates of the                      If you are authorizing the release of information from a
            Information                       specific date or date range, enter in those dates;
                                              otherwise leave blank.

                                                                                                                                   Continued on next page
                                        An independent licensee of the Blue Cross and Blue Shield Association.
                        Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc.
                                             ® Registered marks Blue Cross and Blue Shield Association.
Instructions for the Individual and Psychotherapy Notes
Authorization Forms, Continued


Section E     Purpose of the Release of Information

                   Field                                             Member’s Task
              Check Boxes                       Select one of the two boxes:
                                                • At the request of the individual named in Section A
                                                • If not requested by the individual named in Section A,
                                                  indicate the purpose for the release of information.


Section F     Expiration Date – This authorization will terminate for one of the following
              three reasons, whichever occurs first:

              1. The date on which the individual’s coverage ends (only if disclosure is
                  requested by the insurance company);
              2. One year from the signature date you enter;
              3. Upon the date, event or condition you enter

              Note: “Indefinitely” may not be used to indicate the duration of the
              authorization.


Section G     Signature and Date

              Enter the name of the adult member, parent on behalf of a minor or legal
              representative.
              The name must be printed and then signed with a date.

              Note: The form is invalid without a date and will be returned to you. The form
              will expire one year from the date provided unless your coverage ends or you
              have indicated. “Indefinitely” may not be used to indicate the duration of the
              authorization.


Address and   Please contact Member Services at the number on the back of your health
Fax           plan ID card.
Information

                                          An independent licensee of the Blue Cross and Blue Shield Association.
                          Anthem Blue Cross and Blue Shield is the trade name of Rocky Mountain Hospital and Medical Service, Inc.
                                               ® Registered marks Blue Cross and Blue Shield Association.