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Privacy Practice Notice and Forms

Privacy Practices Notice

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) helps to protect your privacy. If you are covered by a health plan, you should get a Privacy Practices Notice.

Blue Cross and Blue Shield of Illinois is required by federal and state law to give a Privacy Practices Notice to plan members. The notice explains how BCBSIL can use and share a member’s health and financial information.

Privacy Practices Notice

Privacy Forms

You have certain rights related to your privacy. To make a request regarding these rights, use a privacy form. You can:

  • Print out a form. Complete and sign the form, then mail it to the address shown on the form.
  • Request to have a certain form sent to you. Call the Member Services number shown on your member ID card.
     

Member Authorization Form
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.

Privacy Questions or Concerns

Do you have questions or concerns about your privacy rights?  

  • Call: Use the customer service number on your member ID card. Or you can call 1‑877‑361‑7594. 
  • Write to:
    Privacy Office
    300 East Randolph
    Chicago, IL 60601-5099

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