Privacy Forms

As described in the Privacy Practices Notice, you have certain rights related to your privacy. In order to exercise one of these rights, please print out a form from the list below. Once you complete the form, sign and mail it to the address shown on that form. You can also call the number on the back of your member ID card to ask for a copy of the form you want.

• Standard Authorization Form with Instructions 
• Request to Access PHI 
• Request to Amend PHI 
• Request for Accounting of PHI Disclosures 
• Response to Denied Amendment 
• Confidential Communications Request 
• Restriction Request 
• Privacy and Security Complaint 

Do you have any questions or concerns about your privacy rights? Call the number on the back of your medical ID card, or call us at 877-361-7594. You may also write to:

Privacy Office
P.O. Box 804836
Chicago, IL 60680-4110

V1.0-2017