In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Health Information Technology for Economic and Clinical Health Act of 2009 and the Genetic Information Nondiscrimination Act, the Motion Picture Industry Health Plan is required to maintain the privacy of your personal and protected health information ("PHI").

Our policy requires your written authorization for disclosures beyond those specifically identified situations listed in our HIPAA Special Privacy Notice. The Notice/policy also spells out your rights to:
  • Review your personal information
  • Grant access to or restrict use of your health information
  • Request that MPI add information to your records
  • Receive an accounting or copy of your information shared by MPI with another party
If you have any questions regarding your patient privacy and other privacy rights, please contact Julia Nicholson, Office of the CEO at 818-769-0007 ext. 336 or by mail at MPI Pension and Health Plans, P.O. Box 1999, Studio City, CA 91614-0999.

Use the table below to find the forms required for each desired task. Then, return your completed forms to MPI by email to service@mpiphp.org or by mail to:

Claims Department--Confidential
MPI Health Plan
P.O. 1999
Studio City, CA 91614-0999

  • Privacy and HIPAA FORMS
    • Review Your Personal Information
      • Form Description
        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. 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 if 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).
    • Grant Access to or Restrict Use of Your Health Information
      • Form Description
        MPIHP Authorization Form Authorizes MPIHP to disclose your health information.
        Generic Provider Authorization Form Participants and others may authorize individuals or organizations to disclose your health information.
        Authorization Revocation Form If you authorize the MPI Health Plan to use or disclose your health information, you may revoke that authorization in writing.
        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.
        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.
    • Request that MPI Add Information to Your Records
      • Form Description
        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.
    • Receive an Accounting/Copy of Your Info Shared by MPI with Another Party
      • Form Description
        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.
        Right to Request Access You have a right to obtain a copy of health information that is used in making decisions about your healthcare, including: enrollment, payment, claims adjudication.

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