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HIPAA Forms

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Health Insurance Portability & Accountability Act

Notice of Privacy Practices
BCNEPA's Notice of Privacy Practices explains how medical information about our members may be used and disclosed and how our members can get access to such information. Additionally, the notice describes our member's rights and details BCNEPA's legal duties with respect to protected health information.

Authorization Form
This form is to be used to obtain an authorization from a member or a member's personal representative to disclose the member's health information to an individual or organization outside of BCNEPA. This form is used when the information is being disclosed for purposes other than treatment, payment or health care operations; when psychotherapy, HIV, mental health or substance abuse information is being disclosed; or when written documentation is needed to show that a member has authorized another to receive specific information about them.

Plan Sponsor's Certification Form
This form certifies that a group has amended their plan documents to comply with the HIPAA Privacy Regulations.

Plan Sponsor's Medicare Certification Form
This form certifies that a group has amended their plan documents to comply with the HIPAA Privacy Regulations in order to receive PHI as required by Center for Medicare Services (CMS) for the retiree drug subsidy (Medicare Part D).

Agreement for Self-Funded Disclosure Request Form
This form permits a self-funded group to provide BCNEPA with a list of employees and/or TPAs/Brokers who can receive claims and enrollment information on behalf of the group.

Agreement for Fully Insured Enrollment Disclosure Request
This form permits a fully insured group to provide BCNEPA with a list of employees and/or brokers who can receive enrollment information on behalf of the group.

Personal Representative Form
This form is to be used to appoint an individual as your personal representative. A personal representative can act on behalf of a member in making decisions related to the member's health care. In order to appoint someone as your personal representative, you must send in valid court documentation that names another individual as having the authority to act on your behalf. The types of documentation that we will accept are Power of Attorney, Court Orders, Guardianship papers, Short Certificate, Letters of Administration, and Letters of Testamentary. We cannot appoint a Personal Representative unless we have the appropriate documentation on file with us.