Healthcare Information Non-Disclosure Request Form
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1
2Healthcare Information Non-Disclosure Request
Premera Blue Cross sometimes needs to disclose (share or give out) your protected personal information (PPI). Use this form to ask
us not to share your PPI with someone that you name. You must confirm that sharing your PPI could affect your safety or that of your
child(ren). We will respond to all reasonable requests.
Do not use this form to change your address or provide an alternate address for reasons that do not involve personal safety.
For address changes that do not involve personal safety (e.g., primary residence, changes in custody/location of minor, college
students, vacation addresses, etc.), please call Customer Service at the number on the back of your member ID card.
This form must be fully filled out to be processed. We will act upon your request within 15 working days of its receipt.
A. IDENTITY of MEMBER
: ________________________________________
________________
Member Name
Date of Birth:
(First/MI/Last)
(MM/DD/YY)
Member #: _____________________________________
________________________________________
Current Address:
City: ____________________________________
(
)
State: _____ ZIP: ___________ Phone:
_______________________________
______________________________________
________________
Subscriber Name:
Subscriber Group Number:
(First/MI/Last)
B. PERSON
B. WHOM SHOULD WE NOT SHARE YOUR PPI WITH?
This request must identify a specific person. If this person is a healthcare provider, we may need to share your PPI for the payment of
healthcare services rendered to you by that provider.
Name: ________________________________
□
□
Relationship to Member:
Spouse/Domestic Partner
Parent/Legal Guardian
□
□
Previous Healthcare Provider
Other (please describe): ____________________________
IMPORTANT:
Check here to certify that the sharing of all or part of your PPI could affect your safety or that of your minor child(ren).
C. ALTERNATE MAILING ADDRESS
Where do you want us to send written information for you or your child(ren) (e.g., Explanations of Benefits):
□
To your current address listed in section A
□
Alternate mailing address (please complete below):
011710 (01-2012)
An Independent Licensee of the Blue Cross Blue Shield Association
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