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:
Request for access to protected health information (PHI)
Request for access to protected health information, English (PDF, 81 KB)
Request for access to protected health information, Spanish (PDF, 79 KB)
Request for access to protected health information, Arabic (PDF, 144 KB)
Request for access to protected health information, Armenian (PDF, 107 KB)
Request for access to protected health information, Chinese (Simplified) (PDF, 185 KB)
Request for access to protected health information, Chinese (Traditional) (PDF, 228 KB)
Request for access to protected health information, Farsi (PDF, 159 KB)
Request for access to protected health information, Hindi (PDF, 109 KB)
Request for access to protected health information, Hmong (PDF, 78 KB)
Request for access to protected health information, Khmer (Cambodian) (PDF, 91 KB)
Request for access to protected health information, Korean (PDF, 183 KB)
Request for access to protected health information, Russian (PDF, 167 KB)
Request for access to protected health information, Tagalog (PDF, 77 KB)
Request for access to protected health information, Vietnamese (PDF, 129 KB)
Request for an accounting of disclosures
Request for an accounting of disclosures, English (PDF, 69 KB)
Request for an accounting of disclosures, Spanish (PDF, 67 KB)
Request for an accounting of disclosures, Arabic (PDF, 155 KB)
Request for an accounting of disclosures, Armenian (PDF, 95 KB)
Request for an accounting of disclosures, Chinese (Simplified) (PDF, 202 KB)
Request for an accounting of disclosures, Chinese (Traditional) (PDF, 197 KB)
Request for an accounting of disclosures, Farsi (PDF, 133 KB)
Request for an accounting of disclosures, Hindi (PDF, 96 KB)
Request for an accounting of disclosures, Hmong (PDF, 67 KB)
Request for an accounting of disclosures, Khmer (Cambodian) (PDF, 80 KB)
Request for an accounting of disclosures, Korean (PDF, 169 KB)
Request for an accounting of disclosures, Russian (PDF, 138 KB)
Request for an accounting of disclosures, Tagalog (PDF, 66 KB)
Request for an accounting of disclosures, Vietnamese (PDF, 142 KB)
Request for amendment of protected health information (PHI)
Request for amendment of protected health information, English (PDF, 69 KB)
Request for amendment of protected health information, Spanish (PDF, 66 KB)
Request for amendment of protected health information, Arabic (PDF, 133 KB)
Request for amendment of protected health information, Armenian (PDF, 89 KB)
Request for amendment of protected health information, Chinese (Simplified) (PDF, 160 KB)
Request for amendment of protected health information, Chinese (Traditional) (PDF, 242 KB)
Request for amendment of protected health information, Farsi (PDF, 115 KB)
Request for amendment of protected health information, Hindi (PDF, 91 KB)
Request for amendment of protected health information, Hmong (PDF, 66 KB)
Request for amendment of protected health information, Khmer (Cambodian) (PDF, 78 KB)
Request for amendment of protected health information, Korean (PDF, 108 KB)
Request for amendment of protected health information, Russian (PDF, 137 KB)
Request for amendment of protected health information, Tagalog (PDF, 65 KB)
Request for amendment of protected health information, Vietnamese (PDF, 121 KB)
Authorization for the release of health information
Authorization for the release of health information, English (PDF, 102 KB)
Authorization for the release of health information, Español (PDF, 102 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 restriction of use or disclosure of protected health information (PHI)
Request for restriction of use or disclosure of protected health information, English (PDF, 75 KB)
Request for restriction of use or disclosure of protected health information, Spanish (PDF, 72 KB)
Request for restriction of use or disclosure of protected health information, Arabic (PDF, 142 KB)
Request for restriction of use or disclosure of protected health information, Armenian (PDF, 90 KB)
Request for restriction of use or disclosure of protected health information, Chinese (Simplified) (PDF, 166 KB)
Request for restriction of use or disclosure of protected health information, Chinese (Traditional) (PDF, 243 KB)
Request for restriction of use or disclosure of protected health information, Farsi (PDF, 135 KB)
Request for restriction of use or disclosure of protected health information, Hindi (PDF, 97 KB)
Request for restriction of use or disclosure of protected health information, Hmong (PDF, 72 KB)
Request for restriction of use or disclosure of protected health information, Khmer (Cambodian) (PDF, 82 KB)
Request for restriction of use or disclosure of protected health information, Korean (PDF, 115 KB)
Request for restriction of use or disclosure of protected health information, Russian (PDF, 156 KB)
Request for restriction of use or disclosure of protected health information, Tagalog (PDF, 71 KB)
Request for restriction of use or disclosure of protected health information, Vietnamese (PDF, 123 KB)
Appointment of representative (AOR) 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, 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, Khmer (Cambodian) (PDF, 128 KB)
Appointment of representative form, Korean (PDF, 153 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)
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 crotected health information (PHI), Español (PDF, 85 KB)
Request for confidential communication of protected health information (PHI), Arabic (PDF, 186 KB)
Request for confidential communication of protected health information (PHI), Armenian (PDF, 108 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, 206 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)
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.
