Privacy Forms
Authorizations to Disclose Health Information (ADHI)
Use the ADHI form to grant Highmark and its subsidiaries and affiliates permission to share your information with trusted individual(s) that you choose.
Revocation of Authorization to Disclose PHI
You may request that we terminate previously granted permission for Highmark to release or disclose a member’s protected health information to other individuals.
Request for Access
If you would like to view or receive a copy of your Highmark maintained protected health information, please submit a request for access.
Request for Accounting of Disclosures
You may request a list of disclosures Highmark made of a member’s protected health information. Disclosures made for payment and health plan operations are excluded from this process.
Request for Restriction
Use this form to request limits or restrictions on disclosures of protected health information to others such as a family member, friend, spouse, doctor, or any other party.
Request for Amendment
You may use this form to request a correction to Highmark created protected health information that you believe is inaccurate or incomplete.
Request for Confidential Communications
Use this form to request that Highmark communicate protected health information in a different way during life-threatening situations. Examples of alternate communications could include telephone, mail, e-mail, or a different address.