Regence Individual Agent of Record Letter for Alec Gibelyou

This is to certify that Alec Gibelyou has been appointed as agent of record for the policyholder named below, for matters relating to health, dental and vision. This appointment is continuous until another agent is designated by this policyholder.

In its discretion, Regence BlueCross BlueShield of Utah shall accept the change and notify the client, the incumbent and new agent of this change and its effective date. The effective date of the change will be the first of the following month provided the request is received by the 25th of the month.

Please review important Notes below.

Policyholder Information
Policyholder's Printed Name:
Policyholder's ID number (if unknown, please provide DOB and Address or Application ID):
Policyholder's Signature & Date:

Agent Information
New Agent Name: Alec Gibelyou
New Agent's ID number: 20558507
Current Agent* (if known):
Current Agent ID* (if known):

Send request to:
Email: ProducerRelationsSupportUT@regence.com Subject: AOR Request
Secured Fax: (888) 734-3807 Attn: AOR Request

Important Notes:
1. Requests must be received b the 25th of the month for an effective date of the 1st of the following month. If received after the 25th they are effective the 1st of the next month.
2. AORs must be signed by the policyholder.
3. The new agent must be appointed with Regence BlueCross BlueShield of Utah.
4. All fields are required except * (if known). Incomplete forms may be returned for completion.
5. A letter signed by the policyholder will be accepted if it contains all required information.


Authorization to Disclose Protected Health Information

By providing your email address, you authorize us to use the email you have provided to confirm that this Authorization to Disclose Protected Health Information form has been implemented or to obtain any missing or necessary additional information to implement it.

If you have more than one Regence insurance policy, we will apply this authorization to all policies.

I authorize Regence to disclose the following information:
☒ Enrollment, eligibility, benefit information
☒ Claims, claim status, and claim history
☒ Medical records and diagnosis
☒ Premium and billing information
☒Alcohol/substance abuse*
☒ Appeals
☒ Pre-authorization
☒ Other

This information may contain sensitive data, including data related to treatment of sexually transmitted diseases, HIV/AIDS, mental health, and reproduction or contraception (including prenatal care and abortion), gender dysphoria, gender affirming care, and domestic violence.

I authorize Regence to disclose the information identified above to the following person(s) or entity(ies):

Alec Gibelyou - Agent
Utah Avenue Insurance
801-609-8699
910 E 100 N, Ste 105
Payson, UT 84651

You must choose one:
The purpose of this disclosure is: ☒ to assist me with my health plan OR  other

This authorization is valid for two years from the date of my signature. I may cancel this authorization at any time by sending written notice to Regence, PO Box 1106, Lewiston, ID 83501-1106. Cancellation of this authorization will not affect any actions taken by Regence before receiving my cancellation notice. I understand completing this authorization is not a condition to receive treatment, payment, enrollment or eligibility. Regence is not responsible for any action taken by an authorized recipient of my protected health
information. I am aware that once Regence discloses my information to an authorized recipient the privacy protections provided by law may no longer apply

*Note: I understand that my substance abuse records are protected under Federal law (42 CFR Part 2) and cannot be disclosed without my written consent unless otherwise provided for in 42 CFR Part 2. I also understand that I may cancel this approval at any time, as described above.

Please return completed form to Regence: PO Box 1106, Lewiston, ID 83501-1106 or email it to MemberMaintenance@regence.com