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USAble Mutual Insurance Company

Privacy Forms

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 [pdf, 606 KB]
    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.

  • Request for Accounting [pdf, 572 KB]
    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 healthcare operations.

  • Request for Confidential Communications [pdf, 572 KB]
    You have the right to request that we keep communications with you confidential and communicate in an alternate manner.

  • Request for Restrictions [pdf, 573 KB]
    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 [pdf, 620 KB]
    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 [pdf, 624 KB]
    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 you.