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HIPAA

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please note: this notice is intended for our fully insured/premium members. Those members of a self-funded plan should obtain a plan from your employer/group health plan.

Notice of Privacy Practices

Privacy Forms
Standard Authorization Form (Microsoft Word)
Standard Authorization Form (Adobe pdf)
Instructions for Completing the Standard Authorization Form (Microsoft Word)
Access Request (Adobe pdf)
Disclosure Accounting Request (Adobe pdf)
Amendment Request
(Adobe pdf)
Response to Denied Amendment (Adobe pdf)
Confidential Communications Request (Adobe pdf)
Restriction Request (Adobe pdf)
HIPAA Complaint (Adobe pdf)



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