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Patient Authorization Protected Health Information Release

You must agree to our Use Agreement below before using this feature.

Use Agreement

Unauthorized access to or use of any information or BCBSKS material provided through any BCBSKS Web site is subject to federal civil and criminal penalties. By using the secure services offered on this Web site, you are agreeing to the following conditions:

For the primary member whose name and identification number appear on the identification card, we provide access for (1) the primary member and for (2) minor children covered under the same membership. The primary member may not access Protected Health Information for any other adults covered under the same membership unless he or she has been authorized by an Patient Authorization for Release of Protected Health Information (HIPAA form), appointment as guardian and/or conservator, or through an appropriate power of attorney.

For additional information, see our Privacy Policy and Legal Notices. If you do not want to accept these conditions of use, please exit the site and contact BCBSKS by telephone, in person or by mail.

By checking this box, I confirm that I (1) am the primary member, (2) have been authorized by the primary member as documented by the completed Authorization for Release of Protected Health Information previously submitted to BCBSKS to act on his/her behalf, or (3) am an adult dependent included on the primary member's coverage. I have read and agree to the Use Agreement for these services. I understand that if I do not agree to these terms, BCBSKS may deny me access to all secure services available now or in the future.

I Agree