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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.


Privacy Questions or Concerns

Do you have any questions or concerns about your privacy rights? Call the number on the back of your member 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

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

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