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HIPAA Notice and Privacy Forms

HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please note: this notice is intended for our fully insured/premium members. Those members of a self-funded plan should obtain a plan from your employer/group health plan.

Notice of Privacy Practices

Privacy Forms

Standard Authorization Form with Instructions (with fill-in fields)

Standard Authorization Form with Instructions

Access Request

Disclosure Accounting Request

Amendment Request

Response to Denied Amendment

Confidential Communications Request

Restriction Request

HIPAA Complaint

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
© Copyright 2012. Health Care Service Corporation. All Rights Reserved.

Important Information about Blue MedicareRx^SM

^SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

^® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

A stand-alone prescription drug plan with a Medicare contract.

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