The forms listed on the menu below are for use by members. These forms are in
portable document format (PDF). You may print and copy as needed.
Note: Some employers use customized forms or electronic
systems. Please check with your Human Resources office.
Use these forms to request a change to your current policy, such as name
changes, deductible amounts, dependent status and more.
We want to pay your eligible claims as fast as possible, so use these forms to
These printable forms allow you to exercise your privacy rights in the most
efficient manner. By printing, completing and sending these forms to the
Privacy Office, your request will be processed efficiently because we will
have the information needed to fulfill the request.
- Authorization for release form
You have the right to authorize Arkansas Blue Cross Blue Shield to
disclose information regarding claims, payments or other communications to
any person or entity.
- HIPAA PHI disclosure form
- Request for accounting
You have the right to request a listing of any disclosures we have made
of your protected health information for purposes other than payment or
- Request for confidential communications
You have the right to request that we keep communications with you
confidential and communicate in an alternate manner
- Request for restrictions
You have the right to request that we restrict the use of your protected
health information for payment and healthcare operations.
- Request to correct or amend record
You have the right to request that any information we created about you
be amended if you believe that it is incorrect.
- Request to inspect health information
You have the right to inspect or get a copy of records we maintain about
you in a designated record set and which we used to make a decision about