If you have a BCN AdvantageSM plan, you must send us this completed form before we can share your protected health information, also known as PHI, with an individual or organization.
©1996-2024 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.