HIPAA Authorization Notice & Form

  1. Home
  2. /
  3. Medical Benefits
  4. / HIPAA Authorization Notice & Form

HIPAA Authorization Notice & Form

The Privacy Rule requires health plans, health insurance companies and health care providers to protect the privacy of individually identifiable information relating to a person’s physical and mental health. Such information is defined in the Privacy Rule as “protected health information.” Protected health information created or received by or on behalf of the Egyptian Area Schools Employee Benefit Trust for this Plan is referred to in this section as “PHI.” The Privacy Rule permits the Trust to use and disclose PHI for treatment, payment and health care operations, and for other purposes as permitted or required by the Privacy Rule and other federal and state laws, as described in the Notice of Privacy Practices. The Trust will use and disclose PHI only for the purposes and to the extent permitted by the Privacy Rule.

Use And Disclosure Of PHI When Authorized In Writing

You or your personal representative may sign an authorization form authorizing the Trust to use or disclose your PHI for any other specified purpose. The authorization must specify in writing the person to whom the information may be is closed, the nature of the information to be disclosed, any restrictions on the disclosure, and an expiration  date. Click here for an Authorization to Disclose Health Information form. A signed authorization is required for the Trust to disclose PHI created or maintained by or on behalf of this Plan to any other employee benefit plan that is not a health plan, including the life insurance plans offered through the Trust.

Please submit a separate Authorization for Release of Protected Health Information (PHI) form for each plan member for whom HealthSCOPE Benefits is being requested to disclose PHI to a third party. If the form is not completed in it’s entirety as indicated, HealthSCOPE Benefits  will be unable to process your request. Incomplete authorization requests will be returned.

Authorization for Release of Protected Health Information (PHI) form