Protected Health Information and Privacy Forms

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member, use one of these forms to tell us who's allowed to see your personal health information.

These forms are for managing protected health information, which is what we call your private medical information we have on file. 

For example, you can tell us who’s allowed to see your information or you can ask to see your information.

If you have any questions, please contact us.

What you’ll need:

  • Your enrollee ID card
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.

What do you want to do?

©1996-2015 Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. We provide health insurance in Michigan.

State and Federal Privacy laws prohibit unauthorized access to Member's private information. Individuals attempting unauthorized access will be prosecuted.

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