Privacy & Other Forms

Blue Cross Blue Shield of Arizona (AZ Blue) is very protective of our members’ personal health information (PHI). We will only share your information with others when you give us permission to do so, when it is permitted by law, and as described in our Notice of Privacy Practices.

You can always cancel or amend any authorization you give us to release information. Send the cancelation in writing to Blue Cross Blue Shield of Arizona, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-9985; you can fax to 602-544-5661; or you can email to privacy@azblue.com. Tell us the date you would like the cancelation to take effect and include your AZ Blue member ID number. Note that cancelations or amendments do not retroactively affect information that was released prior to your cancelation or amendment being made.

A Confidential Information Release Form (CIRF) does not allow the person you indicate to change or cancel your insurance policy, or to submit healthcare appeals or grievances on your behalf. To change or cancel a policy, apply for coverage, or otherwise manage your policy, we need a Power of Attorney (POA).

Please be aware that there are different types of POA, and they can authorize different things. A Health Care POA allows us to share your health information with the person indicated on the form, and let that person manage your healthcare matters. A Durable POA or Financial POA typically doesn’t cover healthcare matters, but it may. The following chart may be helpful in determining which form to send to us:

Please note that the above chart is very general. POA documents vary, so we need to review the individual documents to see exactly what they authorize.

If you have a POA that you want us to recognize, please mail it to: Blue Cross Blue Shield of Arizona, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-9985; you can fax to 602-544-5661; or you can email to privacy@azblue.com.

Please be sure to include a complete copy of the form. We will review it to see what powers you have given to the person indicated on the form. If the POA is acceptable, we will put it on file allowing the person designated on the form to manage your policy and receive your information. If the POA does not appear to be acceptable, or is incomplete, we will send you a letter asking for a valid form or all pages of the document. If the POA only covers financial matters, we will also include a CIRF, which you will need to fill out and return to us.

A person who has been given “guardianship” of another person is generally able to manage all the person’s health matters. A guardianship will usually have powers like a Health Care POA. “Conservatorship” usually covers managing a person’s financial affairs. They are often like a Financial POA.

If you have been granted guardianship or conservatorship over another person, please mail a copy of the letters of appointment of guardian or conservator to: Blue Cross Blue Shield of Arizona, Attention Privacy Office, PO Box 13466, Phoenix, AZ 85002-9985; you can fax to 602-544-5661; or you can email to privacy@azblue.com. With these papers on file, we can work with the guardian or conservator.

No. You will not need a CIRF if you are the policyholder (or the parent) and have an adult disabled dependent on your policy. However, any other individual calling on behalf of the disabled dependent will need a CIRF form if PHI is being discussed.

You have a right to ask for communications about your health and treatment to be confidential. Fill out the Confidential Communication Form found in the forms section and send it to us at the address found on the form, or you can email it to privacy@azblue.com.