Patients' Rights/Legal Forms

Plan Termination

View Form (applies to all plans)

Disability Certification

Disability Certification for Over-age Dependents

Protected Health Information (PHI)

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
Privacy Office
PO Box 14858
Lexington, KY 40512
Fax: 1-410-505-6692

Medical Information Sharing

Notice of Information Sharing
Opt-Out of Information Sharing
Reversal of Opt-Out of Information Sharing

Advance Directive

Advanced Directive Information Sheet
Maryland Advance Directive
CRISP: The State Designated Health Information Exchange (HIE) for Maryland

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

Notice of Nondiscrimination
Civil Rights Complaint Form