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