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HIPAA
 
The following forms may be printed from your personal computer and sent to the Plan Office via a postal service. All forms are valid only when completed in full.


Please submit all completed forms for processing to:
Health Claims Department--Confidential
MPI Health Plan
P.O. 1999
Studio City, CA 91614-0999


Our forms are in PDF (Portable Document Format). To read and print the PDF forms, you need the free Adobe Acrobat Reader, which may already be installed in your system.
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Notice of Privacy Policy and Practices. The information in this Plan Update defines your rights regarding your personal health information maintained by the Plan. Please review this information carefully. The forms below are available to help you with your requests regarding our Privacy Policy and Practices.
HIPAA PRIVACY RULE FORMS
MPIHP Authorization Form. In order to authorize the MPI Health Plan to disclose your health information (information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996) we require your authorization in writing. We strongly recommend you use this form so that all the necessary information is submitted with your request. MPIHP Authorization Form
Generic Provider Authorization Form. Participants and others may authorize to disclose their health information (information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996) by use of this form where an authorization is required but a form is not offered. Generic Provider Authorization Form
Authorization Revocation Form. If you authorize the MPI Health Plan to use or disclose your health information, you may revoke that authorization in writing at any time. We strongly recommend you use our form so that all the necessary information is submitted with your request. Revocation of Authorization for Release of Health Information Form
Right To Request Confidential Communications. You have the right to request that the MPI Health Plan communicate with you by alternative means or at an alternative location if you feel the disclosure of your health information could endanger you. For example, if it would endanger you to have the Health Plan mail benefit cards, Explanation of Benefits forms, or other materials to your address on file, you can request that this information be sent to a different address. If you wish to receive confidential communications, you must submit your request in writing. We strongly recommend you use our form so that all the necessary information is submitted with your request. Participant Request for Confidential Communications Form
Right to Request Access. You have a right to obtain a copy of health information that is contained in a "designated record set" - records used in making enrollment, payment, claims adjudication, and other decisions. A request to inspect and copy records containing your health information must be made in writing. We strongly recommend you use our form so that all the necessary information is submitted with your request. Request for Access to Protected Health Information Form
Right to Amend Your Records. If you believe that your health information records are inaccurate or incomplete, you may request that the MPI Health Plan "amend" the records. Amending a record does not mean that information is deleted. Amending adds information to the record to ensure that it is accurate and complete. The Plan may deny your request to amend your health information if the Plan did not create the health information, if the information is not part of the Plan's records, if the information was not available for inspection or the information is accurate and complete. A request for amendment of records must be made in writing. We strongly recommend you use our form so that all the necessary information is submitted with your request. Participant's Request to Amend Protected Health Information Form
Right to Request an Accounting of Disclosures. You have the right to request a list of certain disclosures of your health information which, under the Privacy Rule, the MPI Health Plan is required to keep a record. This includes disclosures for public purposes authorized by law, or disclosures that are not in accordance with the Plan's privacy policies and applicable law. However, that accounting does not include disclosures that were made for the purpose of payment or health care operations. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a signed Authorization, or disclosures made prior to April 14, 2003. The request must be made in writing. We strongly recommend you use our form so that all the necessary information is submitted with your request. Participant's Request for an Accounting of Disclosures of Protected Health Information
Right to Request Restrictions. You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on MPI Health Plan's disclosure of your health information to someone involved in the payment of your care. A covered entity is under no obligation to agree to requests for restrictions. If you wish to make a request for restrictions, you must do so in writing. We strongly recommend you use our form so that all the necessary information is submitted with your request. Request for Restrictions on Use and/or Disclosure of Protected Health Information Form
Complaint Form. If you wish to file a formal complaint with the MPI Health Plan because you feel we have not adequately protected your privacy, you must do so in writing. We strongly recommend you use our form so that all the necessary information is submitted with your complaint. HIPAA Compliance Complaint Form You may also file written complaints with the Director, Office for Civil Rights of the U. S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with us or the Director.
The California Small Estate Affidavit. This form would be used in the event a Participant died without naming a personal representative to handle his/her outstanding claims with the MPI Health Plan. This form may be used only if the deceased Participant lived in California and whose gross fair market value of real and personal property in California, excluding the property described in Section 13050 of the California Probate Code, does not exceed one hundred thousand dollars ($100,000).
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