Protected health information and privacy request forms

These forms may be used to exercise your rights for the handling of your personal information as described in the Blue Cross Blue Shield of Michigan and Blue Care Network HIPAA Notice of Privacy Practices (PDF).

For each form, fill in all information requested, print and mail to the address listed at the bottom of the specific form. Read the instructions on the form as some of them may be faxed to BCBSM.

• Authorization for Use and Disclosure of Protected Health Information  (PDF)
  Use this form to authorize BCBSM or BCN to release your protected health information to a person or entity of your choice.
• Authorization for Use and Disclosure of Psychotherapy Notes  (PDF)
  Use this form to authorize BCBSM or BCN to release your psychotherapy notes to a person or entity of your choice.
• Authorization to Revoke a Previous Authorization  (PDF)
  Use this form when you no longer authorize BCBSM or BCN to disclose your protected health information to the person or entity you asked us to send information to under your previous authorization release.
• Request for Access to Designated Protected Health Information Records  (PDF)
  Complete this form to request access to specific information that we maintain about you.
• Request to Amend Protected Health Information  (PDF)
  Complete this form to request an amendment of the information we maintain about you.
• Request for Restriction of Use and Disclosure of Protected Health Information  (PDF)
  Use this form to request restrictions on the way in which we use or disclose your health information.
• Request for Alternate Means of Confidential Communications  (PDF)
  Complete this form to request that we communicate with you about your protected health information using an alternative address or means of communication.
• Revocation of Alternate Means of Confidential Communications  (PDF)
  Use this form when you no longer want BCBSM or BCN to communicate with you about your protected health information using the alternative address or means of communication you previously provided to us.
• Request for List of Disclosures of Protected Health Information  (PDF)
  Complete this form to request a listing of the specific disclosures of your health information that we have made to others.
• Affidavit of Next of Kin — for handling of decedent's health care claim payments  (PDF)
  Use this form when no probate estate will be established for a deceased member. In the form, you will attest that you are the nearest relative of a deceased Blues member and responsible for handling health care bills and payments on the member's behalf. If a probate estate has been established, please send a copy of the court-approved letter of authorization naming you as personal representative.
• Health Care Privacy Practices Complaint Form  (PDF)
  Complete this document to make a complaint about our privacy practices or our compliance with our notice of privacy practices. Alternatively, you can call our Privacy Complaint Line at 1-800-552-8278.
  
  

  You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with their address to file your complaint upon request. We support your right to protect the privacy of your PHI. We will not take action against you if you file a complaint with us or with the U.S. Department of Health and Human Services