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HIPAA Form

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 to complete the form.  


Section 1.  Plan and member information
Section 2.  Employee information: if you are NOT the employee of the plan
Section 3.  Who you authorize to receive your PHI information; for example, spouse, child or friend
Section 4.  Purpose: why do you want the information released?
Section 5.  Your signature and your understanding of what it means
Section 6.  Signature of member or member's guardian    

                           
The member whose information is to be released is required to sign the authorization form.

                     
All sections of the form must be complete for the form to be considered. Please forward this completed form to the privacy officer of the employer or to:  

 

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

 

Print a blank HIPAA form to complete and send to Meritain Health.