CurrentFlorida BluePolicy N/A

Authorization for Disclosure of Protected Health Information (PHI) — Spanish-language member form

This document is a member-facing authorization form that governs how Florida Blue members (or their personal representatives) can permit Florida Blue to disclose their protected health information to third parties; it applies to members of Florida Blue, Truli for Health, and Florida Blue Medicare, Inc. and to disclosures described on the completed form.

Policy Summary

PayerFlorida Blue

PolicyAuthorization for Disclosure of Protected Health Information (PHI) — Spanish-language member form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionMember or personal representative must complete and sign the form to authorize disclosure, specifying recipients, records, purpose, and expiration; attach documentation if signed by a representative.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7document chunks extracted

Multiplesensitive PHI types referenced

Member-facingintended audience

Authorization Conditions

Authorization Criteria

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.

ALL of the following

If signed by a personal representative, attach documentation of authority (e.g., Power of Attorney); form is incomplete without documentation

ALL of the following

Member must specify the name, address, city, state, postal code, and phone number of the person or company to receive PHI

ALL of the following

ONE of
- At my request (no specific purpose)
- Specific purpose: member must select and may provide an example such as to help manage health insurance benefits

ALL of the following

ONE of
- Medical care records
- Specific information as described (e.g., claim related to service on a specified date)

ALL of the following

ONE of
- Authorization expires when member revokes in writing according to the instructions on the form
- Authorization expires on a specified date, event, or condition selected by the member
Revocation instructions: member may revoke at any time by written notice to Florida Blue at the address on the form; revocation is not effective retroactively for disclosures made prior to processing

ALL of the following

Member acknowledges PHI may include information created by other providers or entities and may include sensitive diagnostic/treatment details (chronic disease, mental/behavioral health, substance use disorders, HIV/AIDS, and other infectious diseases)
Member acknowledges that PHI disclosed to persons or organizations outside Florida Blue or Truli for Health may not be subject to federal privacy protections
Authorization is voluntary; enrollment or eligibility for benefits will not change if the member does not sign the form

Member Authorization & Notices

Prior Authorization

Member Authorization and Instructions

Provider action: Member Authorization and Instructions — The member (or the member's personal representative) may authorize Florida Blue (including Florida Blue HMO, Truli for Health, and Florida Blue Medicare, Inc.) to disclose their Protected Health Information (PHI) to named persons or companies for a specified purpose. The member must complete all sections of the authorization form and return the signed form to the address listed on the form. The authorization must identify the person/company to receive PHI (name, address, city, state, ZIP, telephone). The member must indicate the purpose of the disclosure by selecting ONLY ONE option: at the member’s request (no specific purpose) or a specific purpose (e.g., to help manage health benefits). The member must specify which PHI/records are to be disclosed by selecting ONLY ONE option (e.g., medical care, or specific information such as the claim related to services on a particular date).

Complete all sections of the form and return a signed copy to the address on the form.
Provide recipient details: name, address, city, state, ZIP, phone.
Select ONLY ONE purpose for disclosure: at member request OR a specific purpose.
Select ONLY ONE category of records/PHI to be disclosed (e.g., medical care or specific claim information).
Authorization expiration: choose either revocation per instructions or a specified date/event.

Denial Risk

Sensitive PHI and Voluntary Authorization Notice

Provider action: Sensitive PHI and Voluntary Authorization Notice — When signing, the member acknowledges that PHI may include information created by other entities (including health care providers) and may contain sensitive information such as diagnoses and treatment for chronic conditions, mental health/behavioral health conditions, substance use disorders, HIV/AIDS, and other infectious diseases. The member is informed that once PHI is disclosed to persons or organizations outside Florida Blue/Truli for Health, that information may no longer be protected by federal privacy laws. The member may obtain a copy of the signed authorization by sending a signed request to Florida Blue at the address on the form. The member may revoke the authorization at any time by sending a written notice to Florida Blue; revocation does not affect disclosures made prior to receipt and processing of the revocation. Signing the authorization is voluntary and does not affect enrollment or eligibility for Florida Blue/Truli for Health benefits. For questions, members should call Customer Service at the toll-free number on the back of their member ID card.

PHI may include sensitive mental health, substance use, HIV/AIDS, and other infectious disease information.
Disclosures to third parties outside Florida Blue/Truli for Health may not be protected by federal privacy laws.
Member may obtain a copy of the signed authorization by submitting a signed request to Florida Blue at the address on the form.
Member may revoke authorization in writing; revocation won’t affect actions taken before the revocation was received and processed.
Authorization is voluntary; benefits/enrollment are unaffected by refusal to sign.

Key Definitions

Personal representative

DefinitionA personal representative is someone with the legal right to sign this form and act on behalf of the member (e.g., under a Power of Attorney)

Documentation requirementAttach proof of authority (for example, Power of Attorney). The form cannot be accepted without that documentation

When usedComplete the Personal Representative information section if signing on behalf of the member

Protected Health Information (PHI)

ScopeProtected Health Information (PHI) may include information created by other persons or entities, including health care providers

Sensitive categoriesPHI may include sensitive diagnostic and treatment details such as chronic disease, mental/behavioral health, substance use disorders, HIV/AIDS, and other infectious diseases

Third-party disclosuresIf PHI is shared with persons not part of Florida Blue or Truli for Health, it may not be subject to federal privacy protections

OpenPayer

Authorization for Disclosure of Protected Health Information (PHI) — Spanish-language member form

Authorization Conditions

Coding / Expiration Options

Member Authorization & Notices

Key Definitions