Protected Health Information and Privacy Forms

  • These forms are for managing protected health information, or PHI, 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 subscriber ID card, also known as 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.
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Protected health information and privacy form downloads

Member Consent for Release of Protected Health Information (PDF)
You can use this form when you want to let someone or some place see your protected health information.
Request for Release of Member's Protected Health Information (PDF)
You can use this form if you represent someone and need access to their protected health information.
Authorization for Use and Disclosure of Psychotherapy Notes (PDF)
You can use this form when you want to let someone or some place see your psychotherapy notes, which are part of your protected health information.
Authorization to Revoke a Previous Authorization (PDF)
You can use this form when you want to stop sharing your protected health information with a person or place you previously authorized.
Request for Access to Designated Protected Health Information Records (PDF)
You can use this form when you want to see your own protected health information. The HIPAA designated record set includes a complete copy of your health information and any enrollment, claims processing, payment, case and medical notes.
Request to Amend Protected Health Information (PDF)
You can use this form when you want to ask BCBSM to update or make changes to the records we maintain. To make changes to your medical records, you may want to reach out to your doctor.
Request for Restriction of Use and Disclosure of Protected Health Information (PDF)
You can use this form when you want to manage who can and can’t see your protected health information.
Request for Confidential Communication (PDF)
You can use this form to tell us how and where you want us to send confidential information about your protected health records.
Update Method of Confidential Communications (PDF)
You can use this form to update your current method of confidential communications.
Cancel Confidential Communication (PDF)
You can use this form to tell us to stop sending confidential information about your protected health records in a way you previously authorized.
Request for List of Disclosures of Protected Health Information (PDF)
You can use this form to ask us to provide you with a list of certain disclosures of your protected health information.
Affidavit of Next of Kin (PDF)
You can use this form to manage the protected health information of someone who’s passed away.
Health Care Privacy Practices Complaint Form (PDF)
You can use this form to file a complaint about our privacy policies, procedures and practices. You can also file a complaint if you don’t think we’ve complied with our Notice of Privacy Practices, or state and federal privacy rules and laws.

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