HIPAA privacy forms and Certificate of Group Plan Coverage

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 Designation of Personal Representative form.

(file download link) Authorization for Release of PHI

The Designation of Personal Representative 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.

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.

(file download link) Designation of Personal Representative

The Request to Access Protected Health Information form is used to make a request to inspect and/or obtain copies of your protected health information maintained by APWU Health Plan and our Business Associates.

Please note that the APWU Health Plan 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 APWU Health Plan must respond to your written request within 30 days from the date it was received.

(file download link) Request to Access PHI

The Request for an Accounting of Disclosures form allows you to receive an accounting of the disclosures of your protected health information by the APWU Health Plan or our Business Associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request.

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 your 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
• 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 APWU Health Plan 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.

(file download link) Accounting of Disclosures of Protected Health Information

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 APWU Health Plan 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.

(file download link) Confidential Communications

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.

(file download link) Request for Restriction