Privacy Forms

As a Blue Cross and Blue Shield of New Mexico (BCBSNM) plan member, 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 Member Services at 1-866-689-1523 (TTY: 711).

Standard Authorization Form  
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.

Privacy Questions or Concerns

Do you have any questions or concerns about your privacy rights?

  • Call: Member Services 1-866-689-1523 (TTY: 711)
  • Write to: 
    Privacy Office
    Blue Cross and Blue Shield of New Mexico
    300 East Randolph Street
    Chicago, Illinois 60601-5099

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