Privacy forms

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, 97 KB)
Authorization for the Use or Disclosure of Health Information, Chinese (PDF, 164 KB)
Authorization for the Use or Disclosure of Health Information, Hindi (PDF, 133 KB)
Authorization for the Use or Disclosure of Health Information, Korean (PDF, 137 KB)
Authorization for the Use or Disclosure of Health Information, Spanish (PDF, 104 KB)
Authorization for the Use or Disclosure of Health Information, Vietnamese (PDF, 225 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, 71 KB)

Request for Accounting Disclosures (PDF, 113 KB)

Request for Restriction (PDF, 115 KB)

Appointment of Representative form, English (PDF, 1.1 MB)
Appointment of Representative form, Español (PDF, 107 KB)
Appointment of Representative form, Arabic (PDF, 166 KB)    
Appointment of Representative form, Armenian (PDF, 207 KB)
Appointment of Representative form, Cambodian (PDF, 238 KB)
Appointment of Representative form,Chinese (Simplified) (PDF, 241 KB)
Appointment of Representative form, Chinese (Traditional) (PDF, 299 KB)
Appointment of Representative form, Farsi (PDF, 223 KB)
Appointment of Representative form, Korean (PDF, 322 KB)
Appointment of Representative form, Russian (PDF, 150 KB)
Appointment of Representative form, Tagalog (PDF, 196 KB)
Appointment of Representative form, Vietnamese (PDF, 297 KB)
Appointment of Representative form, Hindi (PDF, 348)

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.