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Forms

Paper Based Enrollment Applications - Small & Large Groups

HIPAA Authorization Forms - Members

  • pdf icon HIPAA Form 2(A) - Use/Disclose Protected Health Information Completing this form permits release, in most instances, of general health information to the person(s) named in the form(s). This version does NOT allow for the release of HIV/AIDS, Mental Health, Alcohol or Substance Abuse information.
  • pdf icon HIPAA Form 2(D) Authorization for Release of HIV Information Completion of this form will ONLY allow the release of HIV/AIDS information.
  • pdf icon HIPAA Form 2(E) Authorization for Release of Confidential Medical Records Related to Alcohol and Substance Abuse and Mental Health Completion of this form will ONLY allow the release of Mental Health, Alcohol or Substance Abuse information.
  • pdf icon HIPAA 2(I) - PHI and Online Services Access Form Plan Sponsor Certification of Group Health Plan HIPAA Compliance and Authorization for Third Party Access to PHI.
  • pdf icon How to complete HIPAA2I Form (P)