In order for the APWU Health Plan to disclose information about you that is not for the purposes of treatment, payment or health care operations, you must first authorize a person and/or organization to receive your protected health information. By completing and submitting this Authorization for Release of Protected Health Information Form, you are allowing the designated individual(s) to have access to only the protected health information specified by you on the form.

This form is ideal if you need assistance with handling specific claims or only wish for the designated individual to have limited access to your protected health information that will expire in a timeframe not to exceed one year. It is important to note that this form does not allow the authorized individual(s)/organization(s) to make any health care decisions on your behalf. If you wish to authorize the designated individual to be able to make health care decisions on your behalf, please complete and return a Personal Representative Authorization Form.

Personal Representative Authorization

The Personal Representative Authorization Form allows you to designate a personal representative who will act on your behalf in making decisions related to health care, which includes treatment and payment issues. This individual can be a family member, friend, lawyer or unrelated third party.

Your designated personal representative stands in your shoes and has the ability to act for you and exercise your rights. For instance, at your request the APWUHP must provide your personal representative with an accounting of the disclosures of your protected health information, as well as provide the personal representative access to your protected health information to the extent such information is relevant. In addition to exercising your rights under the Health Insurance Portability and Accountability Act (The Privacy Rule), a personal representative may also authorize disclosures of your protected health information.

This form is ideal if you require ongoing, comprehensive assistance. It is important to understand that the individual you list as your personal representative has the authority to make health care payment related decisions on your behalf. If you require permanent assistance with your health care needs, you may also submit a legal power of attorney to the APWUHP.

Request for Access

The Request for Access Form is used to make a request to inspect and/or obtain copies of your protected health information maintained by APWUHP and our Business Associates.

Please note that the APWUHP reserves the right to deny access to psychotherapy notes, information compiled for legal proceedings, on-going research or obtained from a confidential source. We also reserve the right to deny access if we believe it may cause you any harm, but we must grant you a review procedure.

The APWUHP must respond to your written request within 30 days from the date it was received.

Request for Accounting of Disclosures

The Request for an Accounting of Disclosures Form allows you to receive an accounting of the disclosures of your protected health information by the APWUHP or our Business Associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request; however we are not obligated to account for any disclosure made prior to the Privacy Rule compliance date of April 14, 2003.

The Privacy Rule does not require accounting for disclosures:

• for treatment, payment, or healthcare operations;
• to you or your personal representative;
• for notification of or to persons involved in you health care or payment for health care, for disaster relief, or for facility directories;
• pursuant to an authorization;
• of a limited data set;
• for national security or intelligence purposes;
• to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or
• incident to otherwise permitted or required uses or disclosures.

Accounting for disclosures to health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.

The APWUHP must respond to your written request within 60 days from the date it was received. However, if we are unable to give the requested accounting to you within the 60-day deadline, we will notify you in writing that we will be utilizing our right to a 30-day extension provided we explain the reason for the delay and when we will act on your request.

Request for Amendment

The Request for Amendment Form allows you to ask the APWUHP to amend medical information we have about you that you feel is incorrect or incomplete. You have the right to request an amendment as long as the information is kept by or for the APWUHP. Requests for amendments must provide a reason that supports your request and can be denied by the APWUHP.

The APWUHP may deny your request only if the information was not created by us and the originator is no longer available, access is deniable or the protected health information in question is accurate and complete. If the amendment is denied, APWUHP must accept a written statement of disagreement that will be kept with your designated record set.

The APWUHP must respond to your written request within 30 days from the date it was received.

Request for Confidential Communications

The Request for Confidential Communications Form allows you to request an alternative means or location for receiving communications of protected health information by means other than those that we typically employ. For example, you may request that the Health Plan communicate with you through a designated address or phone number.

The APWUHP must accommodate reasonable requests if you indicate that the disclosure of all or part of the protected health information could endanger you. The Health Plan may not question your statement of endangerment. However, we may condition compliance with a confidential communication request on you specifying an alternative address or method of contact and explaining how any payment will be handled.

Request for Restriction

The Request for Restriction Form allows you to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

In order to view the Notice of Privacy Practices and forms, you will need to have Adobe Acrobat Reader installed on your computer. To download this free program, click on the Get Acrobat Reader button.

The APWU Health Plan reserves the right to modify this legal disclaimer and privacy policy at any time. If you have questions about the privacy statement or the practices of this web site, you should contact information@apwuhp.com.