Privacy Practices Notice and Forms

This notice is for members of BCBSIL Group Plans, Individual and Family Plans, and Medicare Plans.  

BCBSIL Privacy Practices Notice

Medicaid plan members have their own Privacy Practices Notice. Go to:  

Blue Cross Community Health Plans^SM  

Blue Cross Community MMAI^SM (Medicare-Medicaid Plan)

Use the forms below if you are covered by a BCBSIL health plan through your employer, or if you are covered by a BCBSIL Individual or Medicare health plan.

Standard Authorization Form with Instructions 
Use this form to ask BCBSIL to share your protected health information (PHI) with a certain person or entity. 

Request PHI Records 
Use this form to ask BCBSIL for a copy of your PHI records. 

Request to Amend PHI 
Use this form to ask BCBSIL to update your PHI. 

Request for Accounting of PHI Disclosures  
Use this form to get a record of how BCBSIL shared your PHI. 

Response to Denied Amendment 
If you had a request to update your PHI denied by BCBSIL, use this form. You can ask that the original request and the denial be attached to future disclosures of your PHI. 

Confidential Communications Request 
Do you feel your life could be in danger if you get mail at your current address? Use this form to ask BCBSIL to restrict your PHI and communicate with you at an alternate location. 

Restriction Request 
Use this form to ask BCBSIL to restrict your PHI from being used or shared with another person or non-covered entity under HIPAA. 

Privacy and Security Complaint 
Use this form to file a privacy or security complaint with BCBSIL.

Medicaid plan members have their own privacy forms. Go to:

Blue Cross Community Health Plans^SM  

Blue Cross Community MMAI^SM (Medicare-Medicaid Plan)