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HIPAA Form

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The Authorization for Release of Information form is required according to the guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA), specifically 45 CFR § 164.508 of the HIPAA Regulations.

The following is a description of how the form should be completed.

     Section 1 - Plan and member information 
     Section 2 - Who is to release the information, e.g. Meritain Health 
     Section 3 - What information you want released, e.g. all information related to my plan 
     Section 4 - Whom do you want to receive the information, e.g. your spouse, child, friend, etc. 
     Section 5 - Why you want the information to be released 

The authorization should be signed by the member whose information is to be released.

All sections of the form must be completed for the form to be considered. Please forward this completed form to the Privacy Officer of the employer or to:

     Attn: HIPAA Compliance Officer
     Meritain Health
     PO Box 1671
     Amherst, NY 14226-7671

Click here to view a sample completed form.

Click here to print a blank form to complete and send to Meritain Health.