Forms to access or share your Protected Health Information (PHI)
Who is this for?
If you're a Medicare member who needs to access or share your Protected Health Information, also known as PHI, you'll need to fill out a form.
If you want to access your own PHI information or share with someone you designate, you can choose from a digital or printable form. We have different forms based on your specific plan. Digital forms are the easiest way to send us your request. Traditional paper forms that you print out and mail will take longer to process.
PHI forms for Medicare Advantage-PPO plans
Choose one of these options if you are a Medicare Plus Blue PPO member.
- Digital PHI form for Medicare Advantage PPO members
- PHI form for Medicare Advantage PPO members (PDF)
Follow the instructions on the digital form to submit it electronically. Paper forms can be sent via mail or fax to:
Medicare Plus Blue PPO
P.O. Box 44256
Detroit, MI 48244-0256
Fax: 1-866-533-5810
PHI forms for HMO plans
Choose one of these options if you are a BCN Advantage HMO or HMO-POS member.
- Digital PHI form for BCN Advantage HMO or BCN Advantage HMO-POS plans
- PHI form for BCN Advantage HMO or BCN Advantage HMO-POS plans (PDF)
Follow the instructions on the digital form to submit it electronically. Paper forms can be sent via mail to:
BCN Advantage
Mail Code C248
20500 Civic Center Drive
Southfield, MI 48706-4115
PHI forms for Medicare supplement plans
Choose this option if you have a Medicare supplement plan.
Follow the instructions on the digital form to submit it electronically. Paper forms can be sent via mail or fax to:
Blue Cross Blue Shield of Michigan
Mail Code X425
600 East Lafayette Blvd
Detroit, MI 48226
Fax 1-866-392-7528
Still have questions? Call the phone number on the back of your member ID card for help.
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