Privacy Practices 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 Texas (BCBSTX) is required by federal and state law to give a Privacy Practices Notice to plan members. The notice explains how BCBSTX can use and share a member’s health and financial information. The notice is different than the website Privacy Statement.

For Group, Individual, and Medicare Plan Members:

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

BCBSTX Privacy Practices Notice
For Medicaid Plan Members:

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

BCBSTX Medicaid Plans

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 customer service number shown on your member ID card.

For Group, Individual, and Medicare Plan Members:

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.
For Medicaid Plan Members:

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

BCBSTX Medicaid Privacy Forms

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 at 1-877-361-7594.
Write to:
Privacy Office
Blue Cross and Blue Shield of Texas
300 East Randolph
Chicago, IL 60601-5099

1.0-2024

Last Updated: July 07, 2024

Privacy Practices Notice and Forms