HIPAA Notice and Privacy Forms
HIPAA Notice of Privacy Practices
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.
Privacy — Contact Us
If you are concerned that your privacy rights have been violated, you may let us know by calling the number on the back of your member identification (ID) card. If you do not have an ID card and have a privacy concern you can reach us by calling 877-361-7594.
Written communications can be sent to:
Director, Privacy Office
P.O. Box 804836
Chicago, IL 60680-4110
P.O. Box 804836
Chicago, IL 60680-4110
Privacy Forms
Standard Authorization Form
Standard Authorization Form
Instructions for Completing the Standard Authorization Form
Request to Access PHI
Request to Amend PHI
Request for Accounting of PHI Disclosures
Response to Denied Amendment
Confidential Communications Request
Restriction Request
HIPAA Complaint
