CurrentFlorida BluePolicy N/A

Authorization to Share Protected Health Information for Customer Service Inquiries

Form authorizing Florida Blue / Truli for Health customer service to disclose a member's protected health information to designated persons for administration of health, dental, and long-term care products; affects members and their authorized representatives.

Policy Summary

PayerFlorida Blue

PolicyAuthorization to Share Protected Health Information for Customer Service Inquiries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMember (or personal representative) may authorize customer service to disclose PHI to named persons for plan administration and may revoke authorization in writing at any time.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Sections I-VIIIform sections present (by outline)

Multiple named recipientsallows designation of multiple persons to receive PHI

Revocation permittedmember may revoke authorization in writing

Expiration date fieldauthorization includes an expiration date

Disclosure Criteria and Conditions

Stance regarding disclosure and limitations:

Member (or personal representative) authorizes Florida Blue/Truli for Health customer service to disclose the member's Protected Health Information to the named person(s) listed in Section III for customer service related to administration of health, dental, and long‑term care products.

Information disclosed to persons who are not part of Florida Blue or Truli for Health may not be subject to federal privacy laws that limit its use or disclosure.

If a sales agent or an employer benefits representative is named in Section III, Florida Blue/Truli for Health are not responsible for disclosures made by those designated persons.

Authorization is voluntary and is not a condition of enrollment, eligibility for benefits, or claims payment.

Authorization and Revocation Actions

Policy Summary

PayerFlorida Blue

PolicyAuthorization to Share Protected Health Information for Customer Service Inquiries

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMember (or personal representative) may authorize customer service to disclose PHI to named persons for plan administration and may revoke authorization in writing at any time.

SourceLink

On This Page

Prior Authorization

Authorization to Disclose PHI for Customer Service

As member (or personal representative), you may authorize Florida Blue/Truli for Health customer service to disclose your Protected Health Information related to administration of health, dental, and long-term care products to the persons you name on the form. The form warns that information disclosed to persons outside Florida Blue/Truli for Health may not remain subject to federal privacy protections.

Authorization covers PHI disclosures for customer service about plan administration.
Designated recipients are named in Section III (e.g., sales agent, employer benefits representative, family, friends, provider, attorney, organization).
If PHI is shared with persons outside Florida Blue/Truli for Health, federal privacy protections may not apply.

Documentation Required

Revocation of Authorization

The member may revoke this authorization at any time by sending a written notice to the address shown on the form; revocation will not affect any actions Florida Blue or Truli for Health took in reliance on the authorization before they received the written revocation.

Revocation must be submitted in writing to the address on the form.
Revocation does not retroactively invalidate disclosures or actions completed before receipt of the revocation.

Key Definitions

Protected Health Information (PHI) — examples and exclusions

Identification dataName, address, age, gender

Plan coverage informationGeneral and specific details about plan benefits

Claims informationPast, present, and future claims (except periods covered by a Confidential Communications address)

Coordination of BenefitsInformation used to coordinate payment between plans

Designated recipient — who may be named

Named persons allowedSales agent, employer benefits representative, parent/guardian, family members, friends, corporation/organization, law firm, provider

How to list recipientsSection III provides spaces to print multiple named recipients and their relationship to the member

Responsibility for disclosures outside Florida Blue/TruliIf PHI is shared with persons not part of Florida Blue or Truli for Health, federal privacy protections may not apply

Voluntary designationDesignation is voluntary and not required for enrollment, eligibility, or claims payment