AL BCBS Form ENR-469 2010 free printable template

Print Form An Independent Licensee of the Blue Cross and Blue Shield Association Authorization for Disclosure of Protected Health Information This authorization will permit Blue Cross and Blue Shield

How to fill out AL BCBS Form ENR-469

How to fill out AL BCBS Form ENR-469

1. Start by downloading the AL BCBS Form ENR-469 from the Alabama Blue Cross Blue Shield website.
2. Fill out the section labeled 'Employee Information' with your personal details such as name, address, and social security number.
3. Complete the 'Dependent Information' section for any dependents you wish to enroll, providing their names, dates of birth, and social security numbers.
4. Indicate the coverage options you want by checking the appropriate boxes.
5. Review the 'Employer Information' section if applicable, and ensure all employer-related details are accurately filled out.
6. Sign and date the form certifying that all the information provided is true and accurate.
7. Submit the completed form to your employer's HR department or directly to Alabama BCBS as instructed.

Who needs AL BCBS Form ENR-469?

1. Any employee who wishes to enroll in or make changes to their health insurance plan offered by Alabama Blue Cross Blue Shield needs to fill out the AL BCBS Form ENR-469.
2. Dependents of employees who are being added to the health insurance plan also require this form to be completed.

People Also Ask about

What is an authorization for disclosure of protected health information?

A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.

What must be on the authorization form to release PHI?

The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.

What are the 8 requirements of a valid authorization to release information?

Valid HIPAA Authorizations: A Checklist No Compound Authorizations. The authorization may not be combined with any other document such as a consent for treatment. Core Elements. Required Statements. Marketing or Sale of PHI. Completed in Full. Written in Plain Language. Give the Patient a Copy. Retain the Authorization.

What requires authorization from the patient for disclosure of PHI?

The HIPAA Privacy Rule requires that an individual provide signed authorization to a covered entity, before the entity may use or disclose certain protected health information (PHI).

What is the phone number for BCBS of Alabama provider authorization?

Provider Enrollment/Credentialing Call the IVR: 205-220-6765. Fax (provider credentialing applications and related documents): 205-220-9545.

What requires an authorization to release PHI?

A covered entity must obtain an authorization for any disclosure of protected health information which is a sale of protected health information. Such authorization must state that the disclosure will result in remuneration to the covered entity.

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What is AL BCBS Form ENR-469?

AL BCBS Form ENR-469 is a specific form used by individuals and entities in Alabama for reporting health insurance enrollment details to Blue Cross Blue Shield.

Who is required to file AL BCBS Form ENR-469?

Entities that provide health insurance coverage in Alabama, including employers and insurance providers, are required to file AL BCBS Form ENR-469.

How to fill out AL BCBS Form ENR-469?

To fill out AL BCBS Form ENR-469, complete the required fields accurately, including enrollment details, member information, and coverage dates, and ensure that the form is signed and submitted according to the provided instructions.

What is the purpose of AL BCBS Form ENR-469?

The purpose of AL BCBS Form ENR-469 is to facilitate the reporting of health insurance enrollment information to Blue Cross Blue Shield in Alabama, ensuring compliance with state regulations.

What information must be reported on AL BCBS Form ENR-469?

The information that must be reported on AL BCBS Form ENR-469 includes the member's personal details, plan information, enrollment dates, and any other required data specified by Blue Cross Blue Shield.