Authorization Form for Information Release |
Personal Representative Form |
Revocation Authorization Personal Representative Designation |
Access to PHI Form |
Accounting of Disclosures |
Amendment to PHI Form |
Restrict PHI Form |
Terminate Restriction to PHI Form |
Request for Confidential Communications Form This form should be returned to: CareFirst BlueCross BlueShield |
Change Healthcare notifying individuals of data breach. Learn more here.
Patients' Rights/Legal Forms
Protected Health Information (PHI)
Medical Information Sharing
Appeals
Request for Appeal - CareFirst Members who are Virginia Residents
If you are a Virginia resident with CareFirst health care coverage, and you wish to file an external appeal for a denied claim, you may do so with the Commonwealth of Virginia. This process does not apply to residents covered under self-insured accounts.
To access appeals forms, you may visit their website or use the Virginia request for external claim form below:
Virginia External Review Request Form |
Nondiscrimination Forms