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HIPAA Privacy Notices & Forms

For Policyholders

We are required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") to maintain the privacy of our customers' Personal Health Information and to provide customers with notice of our legal duties and privacy practices with respect to their Personal Health Information.

HIPAA Privacy Notice

These forms are used to communicate with us on how your Personal Health Information can be used.

Authorization To Use and Disclose Personal Information

Representative Authorization To Use and Disclose Personal Information

Member Request To Restrict Uses and Disclosures of Personal Health Information

Confidential Communication Request

Privacy Complaint Form

Access Request Form

Amendment Request Form

Disclosure Accounting Request Form