HIPAA Privacy Forms
The following form is available through the Plan office in Ashburn, VA. You may call (1-888-636-NALC) or write to the Plan to request the forms.
To download the HIPAA Privacy Rule - Personal Representative Authorization, click here...
If you are a member of the Plan 18 years old or older, the NALC Health Benefit Plan for Employees and Staff 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 following address if you want to designate a personal representative:
Privacy Officer
NALC Health Benefit Plan for Employees and Staff
P O Box 678
Ashburn, Virginia 20146
