Privacy Practices Notice and Forms

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

BCBSTX Privacy Practices Notice

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

BCBSTX Medicaid Plans

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

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

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

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

Response to Denied Amendment
If you had a request to update your PHI denied by BCBSTX, 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 BCBSTX to restrict your PHI and communicate with you at an alternate location. 

Restriction Request
Use this form to ask BCBSTX 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 BCBSTX.

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

BCBSTX Medicaid Privacy Forms