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 release of health information
Authorization for the release of health information, English (PDF, 96 KB)
Authorization for the release of health information, Español (PDF, 97 KB)
Authorization for the release of health information, Arabic (PDF, 190 KB)
Authorization for the release of health information, Armenian (PDF, 133 KB)
Authorization for the release of health information, Chinese (Simplified) (PDF, 164 KB)
Authorization for the release of health information, Chinese (Traditional) (PDF, 424 KB)
Authorization for the release of health information, Farsi (PDF, 147 KB)
Authorization for the release of health information, Hindi (PDF, 133 KB)
Authorization for the release of health information, Hmong (PDF, 97 KB)
Authorization for the release of health information, Khmer (Cambodian) (PDF, 120 KB)
Authorization for the release of health information, Korean (PDF, 137 KB)
Authorization for the release of health information, Russian (PDF, 177 KB)
Authorization for the release of health information, Tagalog (PDF, 96 KB)
Authorization for the release 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)
Request for Confidential Communication of Protected Health Information (PHI), English (PDF, 104 KB)
Request for Confidential Communication of Protected Health Information (PHI), Español (PDF, 103 KB)
Request for Confidential Communication of Protected Health Information (PHI), Arabic (PDF, 175 KB)
Request for Confidential Communication of Protected Health Information (PHI), Armenian (PDF, 129 KB)
Request for Confidential Communication of Protected Health Information (PHI), Chinese (Simplified) (PDF, 210 KB)
Request for Confidential Communication of Protected Health Information (PHI), Chinese (Traditional) (PDF, 244 KB)
Request for Confidential Communication of Protected Health Information (PHI), Farsi (PDF, 153 KB)
Request for Confidential Communication of Protected Health Information (PHI), Hindi (PDF, 135 KB)
Request for Confidential Communication of Protected Health Information (PHI), Hmong (PDF, 103 KB)
Request for Confidential Communication of Protected Health Information (PHI), Khmer (Cambodian) (PDF, 126 KB)
Request for Confidential Communication of Protected Health Information (PHI), Korean (PDF, 211 KB)
Request for Confidential Communication of Protected Health Information (PHI), Russian (PDF, 179 KB)
Request for Confidential Communication of Protected Health Information (PHI), Tagalog (PDF, 103 KB)
Request for Confidential Communication of Protected Health Information (PHI), Vietnamese (PDF, 207 KB)
Request for Accounting Disclosures (PDF, 113 KB)
Request for Restriction (PDF, 115 KB)
Appointment of Representative form
Appointment of Representative form, English (PDF, 83 KB)
Appointment of Representative form, Español (PDF, 107 KB)
Appointment of Representative form, Arabic (PDF, 177 KB)
Appointment of Representative form, Armenian (PDF, 139 KB)
Appointment of Representative form, Cambodian (PDF, 128 KB)
Appointment of Representative form,Chinese (Simplified) (PDF, 245 KB)
Appointment of Representative form, Chinese (Traditional) (PDF, 322 KB)
Appointment of Representative form, Farsi (PDF, 156 KB)
Appointment of Representative form, Hindi (PDF, 141 KB)
Appointment of Representative form, Hmong (PDF, 107 KB)
Appointment of Representative form, Russian (PDF, 179 KB)
Appointment of Representative form, Tagalog (PDF, 106 KB)
Appointment of Representative form, Vietnamese (PDF, 184 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.
