You can use this form to ask us to provide you with a list of certain disclosures of your protected health information.

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.

If you have any questions, please contact us.

Request for List of Disclosures of Protected Health Information (PDF)

If you'd like more information about what those disclosures are, you can also find that on the form.