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CCRF
Confidential Communications Request Form
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Use this form to request that Blue Cross and Blue Shield of Illinois use an alternative means or an
alternative location when communicating with you about your Protected Health Information (PHI). You
have the right to request that we communicate with you about all or part of your PHI by alternative means
or at an alternative location. We will accommodate your request if all of the following criteria are met:
1. Your request is reasonable;
2. You clearly state that failure to honor your request could endanger you;
3. You provide reasonable alternative means or location for communicating with you, and;
4. You provide a satisfactory explanation how any payments (if applicable) will be handled using the
alternative means or alternative location that you request.
You may also use this form to terminate a previously submitted request for confidential communications.
If you need assistance in completing this form, please call the Customer Service number listed on
the back of your Insurance Identification Card.
This form must be completed entirely. When complete send to:
Blue Cross and Blue Shield of Illinois
P.O. Box 805106
Chicago, IL 60680-4112
Section A:
Is this form being used to terminate a previously submitted request for Confidential Communications? If “Yes”, complete
Section B, then proceed to Section D. If “No”, then complete the form entirely.
Yes – Enter date to terminate previous request:
No Date: month/day/year
Section B: The individual for whom communication by alternative means or at an alternative location is being
requested. Please complete the following:
Name Group # Identification\Subscriber #
Social Security Number Date of Birth
Address City State ZIP
Area Code & Telephone Number E-mail address (if available) Country
Section C: Please complete the following about the confidential communication request:
Will the failure to communicate your PHI through alternative means or at an alternative Yes
No
location endanger you?
Please indicate the PHI that you would like to have communicated by alternative means or at an alternative location:
Rev. 12/12/05 – Privacy Office Page 1 of 2 Confidential Communications Request Form - IL
Blue Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation,
a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services
for Medicare Part D products under HCSC Insurance Services Company's contract number S5715 with the Centers for Medicare and Medicaid Services.
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CCRF
Confidential Communications Request Form
Page 2 of 2
Section C (cont): Please complete the following about the confidential communication request:
I request that my PHI designated above be communicated by the alternative means or at the alternative location listed
below (check only one box):
Mailing Address:
E-Mail Address:
Phone Number:
Fax Number:
Please indicate how any payments (if applicable) will be handled using the alternative means or alternative location that
you request.
Note: If Blue Cross and Blue Shield of Illinois grants this request, the request will only apply to
your current Blue Medicare Rx Number. If you have other membership or change membership to
different coverage, you must submit another Confidential Communications Request form for the
other coverage.
Section D: Signature.
Signature of Individual or Individual’s Personal Representative Date: month/day/year
Section E: If Section D is signed by a Personal Representative, please complete the information below:
Personal Representative’s Name Relationship to Individual
Personal Representative’s Address City State ZIP
Personal Representative’s Area Code & Telephone Number Personal Representative’s E-mail address Country
(if available)
Rev. 12/12/05 – Privacy Office Page 2 of 2 Confidential Communications Request Form - IL
Blue Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation,
a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services
for Medicare Part D products under HCSC Insurance Services Company's contract number S5715 with the Centers for Medicare and Medicaid Services.