American Specialty Health Benefits

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The documents provided below describe how we can use and disclose health information we have about you and how you can access that information. Please refer to the Notice of Privacy Practices (NPP) for details about our current privacy practices. You may contact our Member Services Department at 800-678-9133 if you have any questions.

Privacy Notice:

Privacy Notice Information [PDF]

Member Forms:

Authorization for Release of Protected Health Information [PDF]

Authorized Personal Representative [PDF]

Confidential Communications Form [PDF]

Privacy Complaint [PDF]

Request for Access to Protected Health Information [PDF]

Request for Accounting of Disclosure of Protected Health Information [PDF]

Request to Amend Protected Health Information [PDF]

Request for Restriction of Use/Disclosure of Protected Health Information [PDF]

The documents provided above are in PDF format. In order to view or print these materials you will need Acrobat Reader Version 4.0 or higher.

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