Member Protected Health Information and Privacy Forms

Here you will find forms to help you manage your privacy and protected health information (PHI) that we have on file. PHI includes health information like medical records that have your name, your member number or other information that can identify you. Types of PHI include verbal, written, or electronic information. These forms will let you make decisions about who can see, receive or talk about your PHI.

To learn more about your member rights and our privacy practices, visit our Member Rights and Privacy page

To get started, answer the questions below to help you decide which form you need.

You will need to print the form and mail it to Neighborhood at the address listed on the form. Please make sure to fill out the whole form, including your Member ID and any required signatures. You can also call to request a copy of the form be mailed to you. Please contact the Neighborhood Member Services phone number on the back of your Member ID card to make the request.

What do you want to do?

I want to let another person see, receive or talk about my PHI.
You will need the Member Consent for Release of Protected Health Information form.

I want to receive mail or phone calls at a different phone number.

I want to get a copy of my Neighborhood records, such as pharmacy or claims information.
You will need the Request for Access to Designated Protected Health Information Records form.