The HIPAA Privacy Rule
Forms You May Need

The following forms are available through the NALC Health Benefit Plan office in Ashburn, VA. You may call (1-888-636-NALC) or write to the Plan to request the forms.

If you prefer, you can download the forms from this site.

HIPAA Privacy Rule - Personal Representative Authorization

If you are a member of the Plan 18 years old or older, the NALC Health Benefit Plan will not release your protected health information to anyone except you or someone you have designated as a personal representative, unless the disclosure is to your medical care provider, or is required for our business operations or by law. Complete the HIPAA Privacy Rule Personal Representative Authorization form if you expect someone—your spouse, parent, child, friend, health benefits representative (HBR), or another person—to call or write us on your behalf. You can restrict a personal representative's authority, and you can revoke your authorization to allow someone to act as your personal representative, following the procedures described on the form.

You are not required to name a personal representative, but if you do not, we will not discuss your protected health information, such as diagnoses and treatments, with someone who calls on your behalf. Your authorization does not give your personal representative authority, either implied or direct, over any treatment or direct care decisions.

There is no need to complete a form for a minor child. Generally, unless state law prohibits disclosure, we will discuss a child's protected health information with the child's parent or other person who has legal authority to make health care decisions on behalf of the child.

Mail the completed HIPAA Privacy Rule Personal Representative Authorization form to the address below if you want to designate a personal representative.

Privacy Official
NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149

Request for Access to Protected Health Information (PHI)

Generally, you have the right of access to inspect and obtain a copy of your protected health information maintained by the NALC Health Benefit Plan. This right of access applies to information we maintain in a designated record set, for as long as we maintain it in a designated record set, and it does not apply to the following: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, civil, criminal, or administrative actions; and other information not subject to the right to access information under federal law.

We may charge a cost-based fee for the production and mailing of copies and summaries. Our fees are shown in Section C of the form.

Complete the Request for Access to Protected Health Information form and mail it to the address below, if you wish to request access to protected health information we maintain.

Privacy Official
NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149

Request to Receive Protected Health Information at an Alternative Address

You may request that we mail confidential communications, including explanations of benefits and other correspondence containing protected health information, to an alternative address, if you believe that disclosure of some or al of the information could result in harm to yourself or others. Use the Request to Receive PHI at an Alternative Address form to make your request

If you have designated someone to act as a personal representative, the request that we use an alternate address will not affect that authorization. The person(s) you named still will have access to your protected health information, unless you revoke that authorization, stating the personal representative(s) may no longer act on your behalf. Your revocation must be submitted in writing.

Complete the Request to Receive PHI at an Alternative Address form only if our disclosure of your protected health information could endanger you or others. Mail the completed form to the address below.

Privacy Official
NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149

Authorization for Release of Information form

Occasionally we may need to—or you may want us to—release your specific protected health information for reasons other than for payment of benefits. For instance, when a third party (another person or organization) caused you injury or illness, we will pay benefits for your treatment and care, but we have the right to recover payments made to you by the third party or the third party's insurer, up to the amount we paid because of the illness or injury.

Without your written authorization, we cannot disclose your protected health information, such as the amount we paid in benefits, to the third party's insurer. However, if you sign an Authorization for Release of Protected Health Information form allowing us to release specific information about claims related to the illness or injury, we can work directly with the third party or the third party's insurer to recover the payments we have made. If we cannot disclose the protected health information to the third party or third party's insurer, you will be responsible for reimbursing us the benefits we paid.

Or, you may want us to release protected health information from our records to a new provider, if records are not available from the provider who created them.

Complete the Authorization for Release of Protected Health Information form and mail it to the address below if you want to authorize our release of the specific protected health information described on the form.

Privacy Official
NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149