HIPAA Authorization Form
HIPAA Authorization Form to Disclose Protected Health Information (PHI)
Under the HIPAA Privacy Rule, an individual may authorize release of his or her Protected Health Information (PHI) to a specific person. You must complete the authorization form for BCBSTX to disclose PHI.
Once completed, please mail this form to:
BCBSTX
PO Box 660044
Dallas, TX 75266-0044
If you need assistance with completing this form, please contact BCBSTX Customer Service at
(800) 252-8039.
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