Blue Shield of California Promise Health Plan communications may contain your protected health information (PHI). You can ask to have Blue Shield Promise communications with your PHI sent directly to you at the mailing address you choose. To make this request, submit a Confidential Communications Request form, which can be found here:
|Los Angeles County||San Diego County|
|English (PDF, 71 KB)||English (PDF, 45 KB)|
|Spanish (PDF, 113 KB)||Spanish (PDF, 70 KB)|
|Arabic (PDF, 230 KB)||Arabic (PDF, 185 KB)|
|Armenian (PDF, 174 KB)||Chinese (PDF, 120 KB)|
|Chinese (PDF, 165 KB)||Farsi (Persian) (PDF, 210 KB)|
|Farsi (Persian) (PDF, 233 KB)||Tagalog (PDF, 53 KB)|
|Khmer (PDF, 196 KB)||Vietnamese (PDF, 129 KB)|
|Korean (PDF, 128 KB)|
|Russian (PDF, 168 KB)|
|Tagalog (PDF, 95 KB)|
|Vietnamese (PDF, 171 KB)|
Notice about confidential communication requests:
Members who may consent to receive sensitive services are not required to obtain any other member’s, subscriber’s, or policyholder’s authorization to receive sensitive services or to submit a claim for sensitive services. Blue Shield Promise will direct communications regarding sensitive services to a member’s alternate designated mailing address, email address, or telephone number or, in the absence of a designation, in the name of the member at the address or telephone number on file. Blue Shield Promise will not disclose medical information related to sensitive services to any other member, subscriber’s, or policyholder’s without written authorization from the member receiving care. Blue Shield Promise will accommodate requests for confidential communication in the form and format requested, if it is readily producible in the requested form and format, or at alternative locations. A member’s request for confidential communications related to sensitive services will be valid until the member revokes the request or submits a new request for confidential communications.
A confidential communication request may be submitted in writing to Blue Shield Promise at the mailing address, email address, or fax number at the bottom of this page. A member may, but is not required to, request confidential communications by completing a Confidential Communications Request form. Call Customer Care at (855) 699-5557 (TTY 711) for assistance and to request the form be mailed to you. You can also find and download the form online at blueshieldca.com/promise/medi-cal.
The confidential communication request shall apply to all communications that disclose medical information or provider name and address related to receipt of medical services by the individual requesting the confidential communication.
You may return the completed and signed form to the Blue Shield of California Privacy Office using one of these options:
- Mail: Blue Shield of California Privacy Office
PO Box 272540
Chico, CA, 95927-2540
- Email: email@example.com
- Fax: 800-201-9020
If received by email or fax, your request for confidential communications will take effect within 7 calendar days of receipt. If received by first-class mail, your request will take effect within 14 calendar days of receipt. If you contact us about your request, Blue Shield Promise will acknowledge receipt of your confidential communications request and will advise you of the status of your request.
The confidential communication request will apply to all communications that disclose medical information or provider name and address related to receipt of medical services by the member requesting the confidential communication.