2013 Authorization for Release of Information – Wellness Programs
I authorize Blue Cross Blue Shield of North Dakota (BCBSND) to disclose my protected health information, or personal information if I am not a BCBSND member, to my employer (if my health plan is self-funded) and to designated wellness vendors, to be used for administration of my wellness programs or incentives program(s). If my contract number changes during 2013, this Authorization will transfer to your new BCBSND contract number.
I understand that this Authorization is voluntary. My refusal to authorize disclosure of information to wellness vendors and my employer (if my health plan is self-funded) and will have no effect on my enrollment in BCBSND health plans.
I understand that my protected health information includes, but is not limited to, all data and information in the BCBSND systems, including claims, as a result of medical encounters, treatments, diagnostic tests, screenings, prescriptions, and/or case management activities.
I understand that if the recipient of this information is not a health care provider or health plan covered by federal privacy regulations, this information may be re-disclosed and no longer protected by these federal regulations. My BCBSND health plan is subject to federal privacy regulations and will not re-disclose this information except as allowed by law.
I understand that I have the right to revoke or end this Authorization at any time. I understand that in order to revoke this Authorization I must do so in writing to my BCBSND health plan. I understand that my revocation of this Authorization will not affect any action that has been taken, or any information that has already been used or disclosed, based upon this Authorization before my BCBSND health plan actually received my revocation.
This authorization will remain in effect until 12/31/2013.
I have had full opportunity to read and consider the contents of this Authorization.
I am authorizing the use and/or disclosure of information as described above.
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