CurrentAnthemPolicy N/A

Provider Release of Protected Health Information (PHI) Authorization Form

This document is an Anthem authorization form that governs patient authorization for providers to release protected health and financial information to Anthem and its affiliates; it affects members, providers, and authorized representatives.

Policy Summary

PayerAnthem

PolicyProvider Release of Protected Health Information (PHI) Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Part A to authorize named providers or types of people to disclose the individual's information to Anthem and its affiliates.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Parts A–Fform sections included

sensitive typesexplicitly enumerated

3 optionsexpiration criteria provided

Providedreturn address

Authorization Criteria and Options

Authorization criteria and options

The form permits either full or limited disclosure and lists categories of information that may be disclosed if checked.

Disclosure scope

All my information including health (e.g. diagnosis, claims, provider) and financial information (e.g. premium information, checking account) may be disclosed
Only limited information may be disclosed (member must check all applicable categories below)

If limited information selected, one or more of the following categories may be checked:

Appeal
Physician & hospital

Policy Summary

PayerAnthem

PolicyProvider Release of Protected Health Information (PHI) Authorization Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Part A to authorize named providers or types of people to disclose the individual's information to Anthem and its affiliates.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Authorization and Signature Requirements

Documentation Required

Authorization to Disclose PHI — Complete Part A/B/C

Use this form to authorize named provider(s) or specified types of people in Part A to disclose the individual's protected health information (PHI) to Anthem and its affiliates. Complete all required fields exactly as they appear on the member's ID card and include any supporting documentation requested elsewhere on the form.

Part A: Name of provider(s) or types of people authorized to disclose PHI (e.g., physician, hospital).
Part B: Anthem and its affiliates, Blue Cross and Blue Shield and agents are the authorized recipients.
Part C: Choose whether to authorize disclosure of all information (health and financial) or only limited information; psychotherapy notes require a separate form.

Documentation Required

Legal Representative Signature Requirement — Attach Proof of Authority

If the form is signed by a legal representative or guardian, you must attach documentation that demonstrates the representative's authority to act on the individual's behalf (for example, a Health Care Power of Attorney, court order, or other legal custody documentation). Include the legal representative's printed name, relationship to the individual, signature, and date on the form.

Acceptable documentation: Health Care Power of Attorney, court order, or other legal documentation establishing authority.
Form fields to complete when signed by a legal representative: printed name, legal relationship to the individual, signature, and date.
Note: This form cannot be used to authorize psychotherapy notes; a separate authorization is required for psychotherapy notes.

Authorized Discloser and Sensitive Information

Authorized Discloser

DefinitionDesignated person or types of people authorized to disclose the individual's information (entered in Part A).

Example entryName of Provider (i.e., physician, hospital) or Relationship to the individual — entered in Part A.

ScopeAuthorizes the person(s) listed in Part A to disclose health and financial information to Anthem and its affiliates (Part B names Anthem as recipient).

Sensitive Information

Sensitive types requiring explicit authorizationAbortion; Maternity; Abuse (sexual/physical/mental); Mental health; Alcohol/substance abuse; Sexually transmitted or other communicable diseases; Genetic testing; HIV or AIDS.

Psychotherapy notesPsychotherapy notes are listed separately and excluded — separate form required.

Behavioral health and related categoriesBehavioral Health; Medical records (excludes psychotherapy notes); Pharmacy; Financial; Vision; Dental (selectable under limited information).

OpenPayer

Provider Release of Protected Health Information (PHI) Authorization Form

Authorization Criteria and Options

Billing / Coding References

Provider Authorization and Signature Requirements

Authorized Discloser and Sensitive Information