Privacy Practice 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 Montana (BCBSMT) is required by federal and state law to give a Privacy Practices Notice to plan members. The notice explains how BCBSMT 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 BCBSMT Group Plans, Individual and Family Plans, and Medicare Plans.
BCBSMT Privacy Practices Notice
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:
Use the forms below if you are covered by a BCBSMT health plan through your employer, or if you are covered by a BCBSMT Individual or Medicare health plan.
Standard Authorization Form with Instructions
Use this form to ask BCBSMT to share your protected health information (PHI) with a certain person or entity.
Standard Authorization Form with Instructions
Request PHI Records
Use this form to ask BCBSMT for a copy of your PHI records.
Request to Amend PHI
Use this form to ask BCBSMT to update your PHI.
Request for Accounting of PHI Disclosures
Use this form to get a record of how BCBSMT shared your PHI.
Request for Accounting of PHI Disclosures
Response to Denied Amendment
If you had a request to update your PHI denied by BCBSMT, 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 BCBSMT to restrict your PHI and communicate with you at an alternate location.
Confidential Communications Request
Restriction Request
Use this form to ask BCBSMT 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 BCBSMT.
Privacy and Security Complaint
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 1-877-361-7594.
- Write to:
Privacy Office
Blue Cross and Blue Shield of Montana
300 E. Randolph St.
Chicago, IL 60601-5099
1.0-2024