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This document is used to request a record of disclosures made by Premera Blue Cross regarding member or applicant medical and financial information over the past six years.
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How to fill out request a record of
How to fill out Request a Record of Premera Disclosures
01
Visit the Premera website.
02
Locate the section for 'Request a Record of Premera Disclosures.'
03
Download or access the request form.
04
Fill out your personal information, including name, address, and policy number.
05
Specify the type of disclosures you are requesting.
06
Sign and date the request form.
07
Submit the form via the indicated submission method (mail, email, or fax).
08
Keep a copy of your request for your records.
Who needs Request a Record of Premera Disclosures?
01
Policyholders who want to know how their personal health information has been used and disclosed.
02
Individuals seeking to understand their privacy rights and access their personal health records.
03
Patients who need information for legal, medical, or personal reasons.
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What is Request a Record of Premera Disclosures?
Request a Record of Premera Disclosures is a formal process for individuals to obtain a copy of their medical records and disclosures made by Premera Blue Cross regarding their health information.
Who is required to file Request a Record of Premera Disclosures?
Individuals who seek access to their own health records or authorized representatives acting on behalf of the individual are required to file a Request for a Record of Premera Disclosures.
How to fill out Request a Record of Premera Disclosures?
To fill out the Request, complete the required fields on the form including personal identification information, the specific records requested, and sign the form to authorize the release of the information.
What is the purpose of Request a Record of Premera Disclosures?
The purpose of the Request is to allow individuals to access their health information, ensure accuracy, and understand disclosures that have been made to third parties.
What information must be reported on Request a Record of Premera Disclosures?
The information that must be reported includes the individual's full name, date of birth, relevant account numbers, specific records being requested, and the purpose for the request.
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