Virginia Group Applications and Forms
A variety of applications and other forms are available.
Please contact your Account Manager or Broker Representative to ensure that you have the correct forms. Please choose from the list below:
|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
Viewing and printing this document requires Microsoft Word.