A CCR can be made verbally on the phone or in writing.  Many health insurance companies will have a form they will ask you to fill out if you want to file a CCR.  It might be online or on paper.  If your insurance company doesn’t have a specific CCR form, you can use the form on this website.

Download the Confidential Communications Request.

If you choose to write your own CCR, you have to include the following information:

1. Your name
2. Your insurance card number
3. that you are making a “confidential communication request” (this specific language is important!)
4. The information you want to keep confidential and why.  The insurance company must accept your request if you say one of the following two things:
1. For any sensitive services you might receive.  “Sensitive services" is defined by the law to include, among other services:
1. mental health counseling
2. sexual and reproductive health services (including birth control, abortion, pap smear/ annual exam, STD services)
3. sexual assault services
4. and drug treatment
2. If sharing of all or part of the information that might be revealed in an health insurance communication to the policy holder could lead to harm or harrassment, regardless of the type of health care sought. You don’t have to say why it might endanger you.
5. How you want communications sent to you (email, fax, text, U.S. Mail)
6. Contact information for sending the communication in your preferred method
7. A last-resort mailing address the insurance company can send communications to, in case they aren’t able to send something in the manner requested above

Download the Confidential Communications Request.