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B-1565 Apr-18 Important Facts Regarding Your Authorization to Share Protected Health Information • In order to comply with Federal HIPAA regulations health plans must obtain a member’s permission to share his/her protected health information with any other person. There are limited exceptions to this. • As permitted by law, we will continue to communicate to providers of care involved in your treatment: our payment activities in connection with your claims, your enrollment in our health plan and your eligibility for benefits. • Until a child reaches age 18, parents may access most of their child’s health information without first obtaining the child’s permission. However, regardless of the child’s age, parents do not have access to diagnosis or treatment information for sexually transmitted diseases, abortion, and drug or alcohol abuse unless the child specifically authorizes the release of such information. • This form is used to authorize us to share your protected health information. Each person you identify will have the same access to your information. If you would like each person to access different information or to have access to your information for a different period of time, you’ll need to complete separate forms for each individual or time period. • We will NOT disclose information relating to genetic testing, substance use disorder, mental health, abortion, and sexually transmitted disease information unless you initial the corresponding condition in Part D. If you would like to authorize us to release information regarding HIV/AIDS, New York State requires that a different form be completed. To obtain a copy of this form, please contact our office at the telephone number listed on your identification card, or access the form at the following website: http://www.health.state.ny.us/diseases/aids/forms/informedconsent.htm. • If you need additional forms, you may copy this form, contact our office at the telephone number listed on your identification card or visit our Web site at and search for “Manage Your Privacy”. • Please ensure you have fully completed the form so that we may honor your request. RETAIN A COPY FOR YOUR RECORDS ---PAGE BREAK--- B-1565 Apr-18 AUTHORIZATION TO EXCELLUS HEALTH PLAN, INC. (“HEALTH PLAN”) TO DISCLOSE PROTECTED HEALTH INFORMATION (PHI) Check here only if you are authorizing access to notes. If checked, this form cannot be used for any other purpose. You must complete a separate form for authorizing access to any other information. If this box is checked, skip Part D. PLEASE PRINT PART A: MEMBER/INDIVIDUAL WHO IS THE SUBJECT OF THE INFORMATION TO BE DISCLOSED LAST NAME FIRST NAME MI DATE OF BIRTH IDENTIFICATION # - located on ID card(s) CURRENT ADDRESS CITY STATE/ZIP CODE PART B: HEALTH PLAN CAN SHARE MY INFORMATION WITH THE FOLLOWING PERSON(S) NAME OF PERSON/ORGANIZATION ADDRESS NAME OF PERSON/ORGANIZATION ADDRESS PART C: REASON FOR MEMBER/INDIVIDUAL (PART A) AUTHORIZING DISCLOSURE At my request Other: PART D: HEALTH PLAN CAN SHARE THE FOLLOWING INFORMATION (select D-1 or D-2 and if applicable, D-3) NOTE: Skip this section if was checked at the top of this form - AND, IF APPLICABLE - D-3. Unless specifically indicated below, information will not be disclosed related to the following conditions. If I have placed my initials next to one or more of these conditions, the Health Plan is authorized to disclose information related to those conditions. Genetic testing Substance use disorder Mental health (excluding notes) Sexually transmitted diseases Abortion Note: A separate form must be completed in order to authorize release of information related to HIV/AIDS. The NYS approved form can be found at http://www.health.ny.gov/diseases/aids/providers/forms/informedconsent.htm CONTINUED ON THE NEXT PAGE D-1. I would like you to disclose any information requested by the person or entity named in Part B. This includes information in Part D-3 (below) only if I placed my initials next to the condition. If my initials do not appear in D-3, information related to those conditions will not be disclosed. - OR – D-2. I would like to limit the disclosure of information to a specific type of information, provider, condition or date(s). If this area is blank I do not wish to limit the disclosure of my information. Enrollment (e.g. eligibility, address, dependents, birth date) Benefit (e.g. benefit coverage, usage, limits) Claim (e.g. status, provider, dates, payment, diagnosis) Clinical records (e.g. doctor/facility, case management) Other limitation: Date Range to ---PAGE BREAK--- B-1565 Apr-18 PART E: ACKNOWLEDGEMENT (PLEASE READ AND SIGN) I understand that: • I can revoke this authorization at any time by writing to the Health Plan at the address listed below except this revocation would not affect any action taken by the Health Plan in reliance on this authorization before my written revocation is received. • Information disclosed as a result of this authorization may be re-disclosed by the recipient. Federal and state privacy laws may no longer protect my PHI. • Health Plan will not condition my enrollment in a health plan, eligibility for benefits or payment of claims on my giving this authorization. • Unless you receive revocation in writing, this authorization will be valid until the date specified here: IMPORTANT: I have read and understand the terms of this authorization. I hereby authorize the use and disclosure of my protected health information in the manner described in this form. Signature: Date: If this request is from a personal representative on behalf of the member, complete the following: Personal Representative’s Name: Personal Representative Signature Description of Authority: Parent Legal Guardian* Power of Attorney* Other * * You must provide documentation supporting your legal authority to act on behalf of the member RETURN TO: Excellus Health Plan P.O. Box 21146 Eagan, MN 55121 or Fax: [PHONE REDACTED] Please keep a copy for your records ---PAGE BREAK--- B-5495 Notice of Nondiscrimination Our Health Plan complies with federal civil rights laws. We do not discriminate on the basis of race, color, national origin, age, disability, or sex. The Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or gender. The Health Plan: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, please refer to the enclosed document for ways to reach us. If you believe that the Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Advocacy Department Attn: Civil Rights Coordinator PO Box 4717 Syracuse, NY 13221 Telephone number: 1-[PHONE REDACTED] TTY number: 1-[PHONE REDACTED] Fax: 1-[PHONE REDACTED] You can file a grievance in person or by mail or fax. If you need help filing a grievance, the Health Plan’s Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-[PHONE REDACTED], 1-[PHONE REDACTED] (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ---PAGE BREAK--- B-5495 Attention: If you speak English free language help is available to you. Please refer to the enclosed document for ways to reach us. Atención: Si habla español, contamos con ayuda gratuita de idiomas disponible para usted. Consulte el documento adjunto para ver las formas en que puede comunicarse con nosotros. 注意：如果您说中文，我们可为您提供免费的语言协助。 请参见随附的文件以获取我们的联系方式。 Внимание! Если ваш родной язык русский, вам могут быть предоставлены бесплатные переводческие услуги. В приложенном документе содержится информация о том, как ими воспользоваться. Atansyon: Si ou pale Kreyòl Ayisyen gen èd gratis nan lang ki disponib pou ou. Tanpri gade dokiman ki nan anvlòp la pou jwenn fason pou kontakte nou. 주목해 주세요: 한국어를 사용하시는 경우, 무료 언어 지원을 받으실 수 있습니다. 연락 방법은 동봉된 문서를 참조하시기 바랍니다. Attenzione: Se la vostra lingua parlata è l’italiano, potete usufruire di assistenza linguistica gratuita. Per sapere come ottenerla, consultate il documento allegato. אויפמערקזאם: אויב איר רעדט אידיש, איז אומזיסטע שפראך הילף אוועילעבל פאר אייך ביטע רעפערירט צום בייגעלייגטן דאקומענט צו זען אופנים זיך צו פארבינדן מיט אונז. নজর িদন: যিদ আপিন বাংলা ভাষায় কথা বেলন তাহেল আপনার জনয্ সহায়তা উপলভয্ রেয়েছ। আমােদর েযাগােযাগ করার জনয্ অনুহ কের সংযু নিথ পড়ুন। Uwaga: jeśli mówisz po polsku, możesz z bezpłatnej pomocy językowej. Patrz załączony dokument w celu uzyskania informacji na temat sposobów kontaktu z nami. ﺗﻨﺒﯿﻪ: إذا ﻛﻨﺖ ﺗﺘﺤﺪث اﻟﻠﻐﺔ اﻟﻌﺮﺑﯿﺔ، ﻓﺈن اﻟﻤﺴﺎﻋﺪة اﻟﻠﻐﻮﻳﺔ اﻟﻤﺠﺎﻧﯿﺔ ﻣﺘﺎﺣﺔ ﻟﻚ. ﻳﺮﺟﻰ اﻟﺮﺟﻮع إﻟﻰ اﻟﻮﺛﯿﻘﺔ اﻟﻤﺮﻓﻘﺔ ﻟﻤﻌﺮﻓ ﺔ ﻛﯿﻔﯿﺔ اﻟﻮﺻﻮل إﻟﯿﻨﺎ. Remarque : si vous parlez français, une assistance linguistique gratuite vous est proposée. Consultez le document ci-joint pour savoir comment nous joindre. ﻧﻮٹ: اﮔﺮ آپ اردو ﺑﻮﻟﺘﮯ ﮨﯿﮟ ﺗﻮ آپ ﮐﮯ ﻟﯿﮯ زﺑﺎن ﮐﯽ ﻣﻔﺖ ﻣﺪد دﺳﺘﯿﺎب ﮨﮯ۔ ﮨﻢ ﺳﮯ راﺑﻄہ ﮐﺮﻧﮯ ﮐﮯ طﺮﯾﻘﻮں ﮐﮯ ﻟﯿﮯ ﻣﻨﺴﻠﮏ دﺳﺘﺎوﯾﺰ ﻣﻼﺣﻈہ ﮐﺮﯾﮟ۔ Paunawa: Kung nagsasalita ka ng Tagalog, may maaari kang kuning libreng tulong sa wika. Mangyaring sumangguni sa nakalakip na dokumento para sa mga paraan ng pakikipag-ugnayan sa amin. Προσοχή: Αν μιλάτε Ελληνικά μπορούμε να σας προσφέρουμε βοήθεια στη γλώσσα σας δωρεάν. Δείτε το έγγραφο που εσωκλείεται για πληροφορίες σχετικά με τους διαθέσιμους τρόπους επικοινωνίας μαζί μας. Kujdes: Nëse flisni shqip, ju ofrohet ndihmë gjuhësore falas. Drejtojuni dokumentit bashkëlidhur për mënyra se si të na kontaktoni. A11y 07/03/2018