The Nation's Largest Higher Education Union
To enroll and complete a paper authorization form click HERE and you may fax or mail to the UUP Benefit Trust Fund.
Email: benefits@uupmail.org | Fax: 1-866-559-0516 | Mail: Benefit Trust Fund , PO Box 15143, Albany, NY 12212-9954
In order for the United University Professions Benefit Trust Fund (“Plan”) to use or disclose Protected Health Information (“PHI”) to someone other than you, you must complete this Authorization Form and return it to the Plan’s Privacy Official, Doreen M. Bango.
In order for your medical information to be considered PHI, it must satisfy the following conditions: (a) your medical information must be “health information.” Health information is broadly defined in the applicable HIPAA regulations as meaning any oral or recorded information relating to your past, present, or future physical or mental health, the provision of health care for you, or the payment of health care for you; (b) your medical information must be “individually identifiable.” Individually identifiable health information is broadly defined in the applicable HIPAA regulations as health information that identifies or reasonably can be used to identify you (we may de-identify your individually identifiable health information by removing specific identifiers including, but not limited to your name, social security number, and address); and (c) your medical information must be “created or received” by a covered entity (this Plan and your doctor are covered entities under the applicable HIPAA regulations). Individually identifiable health information that is created or received by a covered entity is protected.
Except as permitted by law, the Plan may not use or disclose PHI to persons other than those you specify on this form. The Plan may request that you complete this form where the use or disclosure of information is necessary to carry out functions of the Plan. In addition, you may submit this form to the Plan because you want someone to request or receive your PHI from the Plan. This form is not needed if you are requesting your own PHI from the Plan. The Plan has a separate form for that type of request.
I,
Any employee of the Plan’s Health Fund Department who assists in the Plan’s administration is an authorized person to disclose PHI.
The specific person(s) (or class of persons) listed below is an authorized person(s) (or class of persons) to receive and use PHI:
For example, “Medical examination report and conclusions related to a fitness-for-work exam, or results of drug testing for employment-related purposes.”
At the request of the Participant or Eligible Dependent (Please check box)
(a) please provide date or event: or
(b) the date the Plan receives your Cancellation of Authorization Form; or
(c) (c) two years from the date you sign this Authorization Form.
Please note that the validity of this authorization cannot extend beyond two years
YES! I agree that submission of this form constitutes my consent to online HIPAA authorization. You will receive an email confirming receipt of this HIPAA authorization form. Please retain a copy of that email for your records.
I understand that:
(a)I have the right to refuse to sign this Authorization Form and that the Plan may not condition Treatment, Payment, enrollment, or eligibility for benefits on whether I sign this Authorization Form except for limited circumstances;
(b) I have the right to revoke this Authorization Form at any time by submitting a Cancellation of Authorization Form to the Plan;
(c) the Cancellation of Authorization Form will take effect as of the cancellation date or event, or once the Plan receives the Cancellation of Authorization Form; and
(d) the specific person(s) or class of persons authorized to receive and use my PHI may not be required to treat this information as confidential.
Join your co-workers in the nation's largest higher education union
