Wellmark Blue Cross and Blue Shield of Iowa (Wellmark) fax number

Fax destination details

Department

Privacy Office

Purpose

PHI release/authORIZATION submissions and related privacy-related forms (e.g., personal representative appointments for PHI access).

Form

T-2618740 Authorization to Release PHI — Authorization to Disclose Protected Health Information

Address

Privacy Office, Mail Station 5W590, PO Box 9232, Des Moines, IA 50306-9232; Wellmark Privacy Office address: 1331 Grand Avenue, Des Moines, IA 50309-2901

Voice phone

515-376-5850

Website

Visit organization website

Before you send

• Confirm that this exact department handles your document or request.
• Check the organization website or call its main line for the current fax number.
• Include a cover sheet and any case, member, claim, or form reference required.
• Keep the delivery confirmation with your submission records.

Fill in the INDIVIDUAL AUTHORIZING DISCLOSURE, specify the Protected Health Information to be Disclosed, list the Persons or Entities Authorized to Receive, set Expiration/Revocation terms, and provide Signature; submit to the Wellmark Privacy Office.

Official form instructions are published as a downloadable file on the organization's website.