HIPAA Authorization Form
HIPAA Authorization Form to Disclose 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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