Do you need access to your family member’s health information, for example, if you routinely call to check on your spouse’s healthcare claims? Or does your family member need access to yours? If so, you and/or your family member need to complete a HIPAA authorization form in 2009 - - even if you have completed one in the past.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to ensure your healthcare privacy. HIPAA mandates that our healthcare plan partners can only discuss your Protected Health Information (PHI) with the individual participant and/or primary plan member - - unless you authorize the plan partners in writing, via the authorization form, to share the information with someone else.
Please click on the form below for access to a PDF copy to print and submit.
HIPAA authorization form - This form is used to allow another individual to have access to your Personal Health Information (PHI). This authorization is good for one year and allows access to all claims and information.
HIPAA DOR (Designation of an Authorized Representative) form - The Designation of Representation (DOR) form allows you to designate an individual to represent you on a specific appealed claim. The DOR form is not the same as the HIPAA authorization form, rather it is used only for specific claim appeals.