HIPAA authorization forms
As part of the Health Insurance Portability and Accountability Act (HIPAA), formal authorization may be required in disclosing personal health information. Here are the authorization forms you may need.
 | Designation of an insurance representative |
 | Use this form if you, as an adult, would like to have an immediate family member (spouse, parent, child, sibling, or domestic partner) handle all insurance issues on your behalf. |
| |
 | Authorization of a third party |
| Use this form if you wish to have the WEA Trust disclose your health information to a third party such as a school district representative, a union representative, an attorney, a neighbor, a friend, an employer, a bank, etc.
|
| |
 | Authorization to a provider |
| Use this form if the WEA Trust needs records from a health care provider (clinic, physician office, hospital, nursing home, etc.), and the provider requires a signed authorization. |
| |
 | Participant revocation of authorization |
| Use this form if you want the WEA Trust to no longer disclose information to an individual or entity whom you authorized to receive your information. Complete the attached “Revocation of Authorization” form.
|
| |
 | Participant right to access protected health information |
| Use this form if you want to inspect or receive a copy of your entire WEA Trust record. |
|
|
 | Request for alternative communications |
| Use this form if you wish to receive communication from the Trust at an address other than the subscriber's or by a means other than the U.S. Postal Service. |
|
|
| |
| |
|
You will need Adobe Acrobat Reader to open the PDF document.
If you don't have it already installed, you can download it now.
|
| |
|
|