Directory Results for AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INATION Full Name Regence ID# Date of Birth I authorize Regence BlueCross BlueShield of Utah (RBCBSU) and Regence ValueCare to disclose the following information: Enrollment, eligibility, and to Authorization To Disclose Protected Health Ination Log # Health Record # Patient Name: Address: City: State: Zip: Date of Birth: Telephone #: Release To Self: Or Name of Person, Company, or Organization Address City, State, Zip