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, 264 KB)
Authorization for the Use or Disclosure of Health Information, Chinese (PDF, 254 KB)
Authorization for the Use or Disclosure of Health Information, Hindi (PDF, 285 KB)
Authorization for the Use or Disclosure of Health Information, Korean (PDF, 306 KB)
Authorization for the Use or Disclosure of Health Information, Spanish (PDF, 236 KB)
Authorization for the Use or Disclosure of Health Information, Vietnamese (PDF, 421 KB)

Request for Access to Protected Health Information (PHI) (PDF, 90 KB)

Request for Amendment of Protected Health Information (PHI) (PDF, 105 KB)

Request for Confidential Communication of Protected Health Information (PHI) (PDF, 78 KB)

Request for Accounting Disclosures (PDF, 113 KB)

Request for Restriction (PDF, 115 KB)

Appointment of Representative Form, English (PDF, 156 KB)
Appointment of Representative Form, Chinese (PDF, 230 KB)
Appointment of Representative Form, Hindi (PDF, 345 KB)
Appointment of Representative Form, Khmer (PDF, 237 KB)
Appointment of Representative Form, Korean (PDF, 255 KB)
Appointment of Representative Form, Spanish (PDF, 146 KB)
Appointment of Representative Form, Vietnamese (PDF, 281 KB)

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: April 15, 2022