Authorization to Disclose Protected Health Information (PHI)

The Health Insurance Portability and Accounting Act (referred to as HIPAA) enacted the privacy provisions of that regulation on April 14, 2003. Access to and disclosure of an individual's protected health information (PHI) is limited to that individual or their designated personal representative.

UniCare Life & Health Insurance Company requires that a designated personal representative be authorized to us in writing. You can retrieve a copy of our Authorization to Disclose Protected Health Information (PHI) by using this link.

When you designate someone to receive your protected health information under the HIPAA regulations, that person(s) becomes your personal representative. Using the Authorization Form, you may further stipulate specific conditions on what type of information your personal representative is eligible to receive. This can be to assist in a single event or to act as your personal representative on an ongoing basis.

Special Note:

• Revocation: You may revoke this authorization at any time.



• No Conditions: This authorization is voluntary. We will not condition your enrollment in a health plan, eligibility for benefits or payment of claims on giving this authorization.



• Effect of Granting this Authorization: The PHI used or disclosed may be subject to re-disclosure by the recipient, in which case it may no longer be protected under the HIPAA Privacy Rule.

About the Authorization Form:

• SECTION A: Individual's name who is authorizing use and/or disclosure (required information)



• SECTION B: The use and/or disclosure being authorized (required information)



• PHI to Be Used and/or Disclosed: Specifically describe the PHI to be used and/or disclosed.



• Entities or Persons Authorized to Use or Disclose: People you authorize to make use of or disclose PHI. UniCare must be included as one of the authorized entities or we cannot disclose to any other person(s) you designate.



• Entities or Persons Authorized to Receive: People and/or organizations (or the classes of persons and/or organizations), including UniCare, that are authorized to receive, and subsequently use and/or disclose your PHI.



• SECTION C: You must stipulate a date or an occurrence when you want the authorization to expire. (required information)

If you have any questions regarding UniCare, please contact our UniCare Customer Service at 800-442-9300.

RETURN COMPLETED AUTHORIZATION FORM TO:

UniCare Life & Health Insurance Company
Andover Service Center
P.O. Box 9022
Andover, MA 01810-0922
Attention: Customer Service Supervisor