The following are forms you, as a Blue Shield member, may use to exercise your privacy rights relating to the health information Blue Shield creates, obtains, and/or maintains about you:

Authorization for the Use or Disclosure of Health Information, English (PDF, 126KB)
Authorization for the Use or Disclosure of Health Information, Chinese (PDF, 312KB)
Authorization for the Use or Disclosure of Health Information, Hindi (PDF, 161KB)
Authorization for the Use or Disclosure of Health Information, Korean (PDF, 310KB)
Authorization for the Use or Disclosure of Health Information, Spanish (PDF, 129KB)
Authorization for the Use or Disclosure of Health Information, Vietnamese (PDF, 288KB)

Request for Access to Protected Health Information (PHI) (PDF, 68KB)

Request for Amendment of Protected Health Information (PHI) (PDF, 52KB)

Request for Confidential Communication of Protected Health Information (PHI) (PDF, 56KB)

To exercise these or any of your other privacy rights, please call the Member Services phone number located on the back of your member ID card.

 

Last updated: February 21, 2018