Notice of Privacy Practices
The privacy components of the Health Insurance Portability and Accountability Act (HIPAA) took effect on April 14, 2003. BlueShield of Northeastern New York continues to comply with federal laws and to meet the required standards for protecting and securing your protected health information (PHI).
To help you understand our responsibilities and your rights under this new legislation, we are providing you with a Notice of Privacy Practices, and the Authorization Forms necessary to share your PHI.
BlueShield's Notice of Privacy Practices describes:
- How we may use and disclose your protected health information.
- Your rights to obtain access to your protected health information.
- Our legal duties relative to your protected health information.
In keeping with the HIPAA Privacy Regulations, the following forms should be used when you wish to give us permission to share your protected health information:
- FORM 2(A), Authorization to use or disclose protected health information (PDF, 33KB File Size) - completion of this form, in most instances, is for the release of general health information — it does not allow for the release of HIV/AIDS, Mental Health, or Alcohol and Substance Abuse information.
- FORM 2(D), Authorization for Release of HIV Information (PDF, 38KB File Size) - completion of this form will ONLY allow the release of HIV/AIDS information.
- FORM 2(E), Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health (PDF, 420KB File Size) - completion of this form will ONLY allow the release of Mental Health or Alcohol and Substance Abuse information.
If you wish to have your general health information released to someone PLUS information regarding HIV/AIDS and/or Mental Health, Alcohol and Substance Abuse, then Form 2 (A) plus one or both of the other forms need to be completed.
Please print the appropriate form(s), complete, and return to the Contact Office given below. We cannot accept the form(s) electronically, as we require your signature on the form(s).
Contact Office - Mailing Address:
PO Box 15013
Albany, NY 12212