Privacy Practices Notice and Forms

This notice is for members of BCBSNM Group Plans, Individual and Family Plans, and Medicare Plans.  

BCBSNM Privacy Practices Notice 

Medicaid plan members have their own Privacy Practices Notice. They get their notice from the state instead of from BCBSNM.

Use the forms below if you are covered by a BCBSNM health plan through your employer, or if you are covered by a BCBSNM Individual or Medicare health plan.  

Standard Authorization Form with Instructions
Use this form to ask BCBSNM to share your protected health information (PHI) with a certain person or entity. 

Request PHI Records
Use this form to ask BCBSNM for a copy of your PHI records. 

Request to Amend PHI
Use this form to ask BCBSNM to update your PHI. 

Request for Accounting of PHI Disclosures
Use this form to get a record of how BCBSNM shared your PHI. 

Response to Denied Amendment
If you had a request to update your PHI denied by BCBSNM, 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 BCBSNM to restrict your PHI and communicate with you at an alternate location. 

Restriction Request
Use this form to ask BCBSNM 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 BCBSNM. 

Medicaid plan members have their own privacy forms. Go to:

BCBSNM Medicaid Plan Privacy Forms