Skip to main content

HIPAA Forms

HIPAA Form 2(A) - Use disclosed/protected health information
Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, mental health, alcohol or substance abuse information.

HIPAA Form 2(D) - Release of HIV Information 
Authorization for release of HIV Information Completion of this form will allow the release of ONLY HIV/AIDS information.

HIPAA Form 2(E) - Release of Confidential Medical Records (related to alcohol, substance abuse, and mental health). 
Authorization for release of confidential medical records related to alcohol and substance abuse and mental health. Completion of this form will allow the release of ONLY mental health, alcohol, or substance abuse information.

CMS Appointment of Representative Form
You can appoint a representative – like a family member, friend, advocate, attorney, doctor or someone else – to act on your behalf. Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.

 

We are available to assist you. 
 

If additional help is needed, contact us at 1-833-735-4512 (TTY: 711)
 

October 1 - March 31, 8 a.m. to 8 p.m., 7 days a week
April 1 - September 30, 8 a.m. to 8 p.m., Monday - Friday

 

Medicare Questions?

We're here to help.

1-833-735-4512 (TTY 711)
Oct. 1 - Dec. 31, 8 a.m. - 8 p.m., 7 days a week
Jan. 1 - Sept. 30, 8 a.m. - 8 p.m., Monday - Friday

BlueShield of Northeastern New York (BSNENY) is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. BSNENY is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711)

Y0086_MRK2319
Content Last Updated October 1, 2018