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Notice of Privacy Policy and Practices. The information in this Plan Update defines your
rights regarding your personal health information maintained by the Plan. Please review this information
carefully. The forms below are available to help you with your requests regarding our
Privacy Policy and Practices. |
HIPAA PRIVACY RULE FORMS
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Authorization Form. In order to authorize the MPI Health Plan to disclose
your health information (information that constitutes protected health information as defined in the Privacy Rule of the Administrative
Simplification provisions of the Health Insurance Portability and Accountability Act of 1996) we require your authorization in writing.
We strongly recommend you use our form so that all the necessary information is submitted with your request.
Authorization for Release of Health Information Form |
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Generic Authorization Form. Participants and others may authorize to disclose
their health information (information that constitutes protected health information as defined in the Privacy Rule of the Administrative
Simplification provisions of the Health Insurance Portability and Accountability Act of 1996) by use of this form where an authorization
is required but a form is not offered.
Generic Authorization for Release of Health Information Form |
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Authorization Revocation Form. If you authorize the MPI Health Plan to use
or disclose your health information, you may revoke that authorization in writing at any time. We strongly recommend you use our
form so that all the necessary information is submitted with your request.
Revocation of Authorization for Release of Health Information Form |
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Right To Request Confidential Communications. You have the right to request
that the MPI Health Plan communicate with you by alternative means or at an alternative location if you feel the disclosure of your
health information could endanger you. For example, if it would endanger you to have the Health Plan mail benefit cards, Explanation
of Benefits forms, or other materials to your address on file, you can request that this information be sent to a different address.
If you wish to receive confidential communications, you must submit your request in writing. We strongly recommend you use our form
so that all the necessary information is submitted with your request.
Participant Request for Confidential Communications Form |
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Right to Request Access. You have a right to obtain a copy of health information
that is contained in a "designated record set" - records used in making enrollment, payment, claims adjudication, and other decisions.
A request to inspect and copy records containing your health information must be made in writing. We strongly recommend you use our
form so that all the necessary information is submitted with your request.
Request for Access to Protected Health Information Form |
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Right to Amend Your Records. If you believe that your health information records
are inaccurate or incomplete, you may request that the MPI Health Plan "amend" the records. Amending a record does not mean that
information is deleted. Amending adds information to the record to ensure that it is accurate and complete. The Plan may deny your
request to amend your health information if the Plan did not create the health information, if the information is not part of the
Plan's records, if the information was not available for inspection or the information is accurate and complete. A request for
amendment of records must be made in writing. We strongly recommend you use our form so that all the necessary information is submitted
with your request.
Participant's Request to Amend Protected Health Information Form |
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Right to Request an Accounting of Disclosures. You have the right to request
a list of certain disclosures of your health information which, under the Privacy Rule, the MPI Health Plan is required to keep a
record. This includes disclosures for public purposes authorized by law, or disclosures that are not in accordance with the Plan's
privacy policies and applicable law. However, that accounting does not include disclosures that were made for the purpose of payment
or health care operations. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed
Authorization, or disclosures made prior to April 14, 2003. The request must be made in writing. We strongly recommend you use our
form so that all the necessary information is submitted with your request.
Participant's Request for an Accounting of Disclosures of Protected Health Information |
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Right to Request Restrictions. You may request restrictions on certain uses
and disclosures of your health information. You have the right to request a limit on MPI Health Plan's disclosure of your health
information to someone involved in the payment of your care. A covered entity is under no obligation to agree to requests for restrictions.
If you wish to make a request for restrictions, you must do so in writing. We strongly recommend you use our form so that all the
necessary information is submitted with your request.
Request for Restrictions on
Use and/or Disclosure of Protected Health Information Form |
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Complaint Form. If you wish to file a formal complaint with the MPI Health Plan
because you feel we have not adequately protected your privacy, you must do so in writing. We strongly recommend you use our form so
that all the necessary information is submitted with your complaint.
HIPAA Compliance Complaint Form
You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services.
We will not retaliate against you if you file a complaint with us or the Director. |
