Privacy Practices Notice and Forms

Privacy Practices Notice

Blue Cross and Blue Shield of Montana (BCBSMT) is required by federal and state law to give a notice to plan members about how we can use and disclose their personal health and financial information. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) helps to protect your privacy. If you are covered by a health insurance plan, you should get a Privacy Practices Notice. The notice tells how your Protected Health Information (PHI) can be used or disclosed.

Privacy Practices Notice
(This notice is different than the website Privacy Statement.)

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 customer service number listed on 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

Privacy Questions or Concerns

Do you have questions or concerns about your privacy rights? Call the customer service number listed on you member ID card, or call us at 1-877-361-7594. You may also write to:

Privacy Office
Blue Cross and Blue Shield of Montana
P.O. Box 804836
Chicago, IL 60680-4110

1.1-2021