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Federal privacy laws prohibit us from disclosing your protected health information to another person or organization without your written authorization (with some exceptions, like your physician). Our Privacy Policy describes other exceptions that may apply.
We're committed to protecting your privacy
If you or a family member (age 18 or older) covered under your contract wish to designate another individual to receive information related to your health insurance and protected health information, please complete a disclosure authorization online or by using the forms below. An authorization form must be completed and returned to us for each person you or your family member wish to authorize.
Download an Authorization Form
  • Print a Copy of the Authorization Form
  • In Spanish
  • Tips for Completing the Form
  • Protected Health Information Authorization Cancellation Form
  • Request to Access Your Protected Health Information
  • Request to Amend Your Protected Health Information
  • Request to Use an Alternate Address/Location when Your Protected Health Information is Communicated to Approved Parties
  • Request an Accounting of Disclosure of Your Protected Health Information
Excellus BlueCross BlueShield contracts with the federal government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_3567_0 Approved.
This page last updated 10/1/2013.
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