Home > Life > Medical Forms > Medical Release Template > Alberta Medical Release Form > Alberta Consent to Disclose of Personal Information Template

Alberta Consent to Disclose of Personal Information Form

At Speedy Template, You can download Alberta Consent to Disclose of Personal Information Form . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.

Alberta Consent to Disclose of Personal Information Form
Alberta Consent to Disclose of Personal Information Form
® The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans.
Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 30662 2013/02
CONSENT TO DISCLOSE PERSONAL INFORMATION
*
*NOTE: This form must be completed by the individual who is the person identified in Section 1, or the person’s parent or guardian if he or she is
under the age of 18.
1.
I hereby authorize Alberta Blue Cross to release personal health and/or benefit plan information relating to the following
person (please print):
LAST NAME FIRST NAME BIRTHDATE
(YYYY MM DD)
ALBERTA BLUE CROSS
ID NUMBER
ADDRESS
PHONE NUMBER (optional)
PROVINCE
POSTAL CODE
2. I hereby authorize Alberta Blue Cross to release the following personal health and/or benefit plan information:
PLEASE CHECK ALL THAT APPLY
benefit plan coverage and registration information, including
account payment
(if responsible for paying premiums)
claims information
(for prescription drugs or dental or health services)
other information
(please describe):
diagnostic, treatment and/or care information
information required for online access to the person’s
benefit plan, claims or account information through
the secure Alberta Blue Cross plan member web site
3.
The above information is to be released for the following purpose(s) (for example litigation, income tax):
4.
The information may be released only to:
THE FOLLOWING INDIVIDUAL(S)
Please note that our corporate privacy policies do not allow the direct release of personal health
information to some third parties, such as the media or pharmaceutical companies or their agents.
FULL NAME
ADDRESS
PHONE NUMBER
RELATIONSHIP
FULL NAME
ADDRESS
PHONE NUMBER
RELATIONSHIP
OR THE FOLLOWING ORGANIZATION
Name of organization
Address
Contact person (s)
Phone number
Purpose
5.
Effective date
This consent is effective on:
YYYY MM DD
and will continue indefinitely unless
an expiry date is indicated to the right:
YYYY MM DD
6. Acknowledgement: Consent may be revoked by me at any time. I understand why I have been asked to provide consent to disclose the per-
sonal health and/or benefit plan information of the person named in Section 1, and am aware of the risks and benefits of consenting, or refusing to
consent, to the disclosure.
Signature of person whose personal health or benefit plan
information is to be released, as named in Section 1, above
(Parent/guardian if person listed in Section 1 is under the age of 18)
Name (please print)
7. PLEASE MAIL TO:
Notes:
Alberta Blue Cross will not accept incomplete consent forms.
This consent is obtained in accordance with section 34 of the Health Information Act, sections 7, 8 and 9 of
Alberta’s Personal Information Protection Act and section 5 of the federal Personal Information Protection and
Electronic Documents Act.
For more information about Alberta Blue Cross privacy policies or the collection, use or disclosure of your/your
dependents’ personal information, visit
www.ab.bluecross.ca, call our privacy matters representative at
1-855-498-7302 or write to Privacy Matters, Alberta Blue Cross, 10009 108 St NW, Edmonton, AB T5J 3C5.
Alberta Blue Cross
Attention:
10009 108 St. NW
Edmonton, Alberta T5J 3C5
Alberta Consent to Disclose of Personal Information Form