Protected Health Information and Privacy Forms
These forms are for managing protected health information, which is what we call your private medical information we have on file.
For example, you can tell us who’s allowed to see your information or you can ask to see your own information.
What you’ll need:
- Your enrollee ID card
- A printer to print the form
- An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.
What do you want to do?
I want to authorize someone to see or receive my protected health information.
You can use this form when you want to let someone or some place see your protected health information.
Member Consent for Release of Protected Health Information (PDF)
I represent someone and want to access that person's protected health information.
You can use this form if you represent someone and need access to their protected health information.
What you’ll need:
- Their enrollee ID card
- A printer to print the form
- An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.
If you have any questions, please contact us.
Request for Release of Member's Protected Health Information (PDF)
I want to let someone see my psychotherapy notes.
You can use this form when you want to let someone or some place see your psychotherapy notes, which are part of your protected health information.
Authorization for Use and Disclosure of Psychotherapy Notes (PDF)
I want to stop sharing information with a person or place I previously authorized.
You can use this form when you want to stop sharing your protected health information with a person or place you previously authorized.
Authorization to Revoke a Previous Authorization (PDF)
I want access to my designated protected health information records that are maintained by Blue Cross Blue Shield of Michigan.
You can use this form when you want to see your own protected health information.
The HIPAA designated record set includes a complete copy of your health information and any enrollment, claims processing, payment, case and medical notes.
Request for Access to Designated Protected Health Information Records (PDF)
I want to update or make changes to my health records.
You can use this form when you want to ask Blue Cross Blue Shield of Michigan to update or make changes to the records we maintain. To make changes to your medical records, you may want to reach out to your doctor.
Request to Amend Protected Health Information (PDF)
I want to restrict use of my protected health information.
You can use this form when you want to manage who can and can’t see your protected health information.
Request for Restriction of Use and Disclosure of Protected Health Information (PDF)
I want to receive health care information at an alternate address because I have concerns about my safety.
You can use this form to tell us how and where you want us to send confidential information about your protected health records.
Request for Confidential Communication (PDF)
I would like to revoke a previous request for confidential communications.
You can use this form to tell us how and where you want us to send confidential information about your protected health records.
Cancel Confidential Communication (PDF)
I want to know who has seen my protected health information.
You can use this form to ask us to tell you who has seen your protected health information.
Request for List of Disclosures of Protected Health Information (PDF)
I'm next of kin for someone who died and need to manage their information.
You can use this form to manage the protected health information of someone who’s passed away.
Affidavit of Next of Kin (PDF)
I have a complaint about your privacy practices.
You can use this form to file a complaint about our privacy policies, procedures and practices. You can also file a complaint if you don’t think we’ve complied with our Notice of Privacy Practices, or state and federal privacy rules and laws.
Health Care Privacy Practices Complaint Form (PDF)
I would like to update my current method of confidential communications
You can use this form to update your current method of confidential communications.