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HIPAA Authorization Form: Authorization To Disclose Protected Health Information

This document is a HIPAA authorization form that allows dependents to authorize HealthEquity, Inc. to disclose their protected health information to the primary account holder. The form provides fields for the primary account holder and dependent's contact information. By completing and signing the form, the dependent grants HealthEquity permission to disclose their protected health information to specified individuals for purposes like family assistance with healthcare or at the dependent's request. The authorization will remain valid for 24-48 months depending on the primary account holder's state of residency, and can be revoked in writing at any time.

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195 views1 page

HIPAA Authorization Form: Authorization To Disclose Protected Health Information

This document is a HIPAA authorization form that allows dependents to authorize HealthEquity, Inc. to disclose their protected health information to the primary account holder. The form provides fields for the primary account holder and dependent's contact information. By completing and signing the form, the dependent grants HealthEquity permission to disclose their protected health information to specified individuals for purposes like family assistance with healthcare or at the dependent's request. The authorization will remain valid for 24-48 months depending on the primary account holder's state of residency, and can be revoked in writing at any time.

Uploaded by

pbnkumar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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HIPAA authorization form

Mail or fax completed forms to:


Address: HealthEquity, Attn: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.727.1005

Authorization to disclose protected health information


Dependents must complete this form to authorize the disclosure of protected health information to the account holder.

Primary account holder information


Last name First name M.I.

Street address City State ZIP

Email address (required) Daytime phone SSN or HealthEquity ID number


( )

HIPAA authorization (to be completed by dependent)


My protected health information is individually identifiable health information, including demographic information collected from me or created
or received by a health care provider, a health plan, my employer, or a health care clearinghouse, and relates to: (i) my past, present, or future
physical or mental health condition; (ii) the provision of the health care to me; or (iii) the past, present or future payment for the provision of
health care to me.
In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA), I, the undersigned, grant permission to
HealthEquity, Inc. to disclose protected health information (as defined in HIPAA) to the following person or persons:

Purpose of authorization: c At my request c Family member assisting with health care c Other:
Any limitations that I impose on HealthEquity with respect to this authorization are declared below:


This authorization will remain in effect for the duration of the state expiration requirement (may vary from 24-48 months) based off of primary
account holder’s state of residency. In addition, I may revoke this authorization at any time by notifying HealthEquity of the revocation in writing
and sending by fax to 801.727.1005, Attn: Member Services.
If at any time you need to alter this authorization form, please contact HealthEquity at 866.346.5800.

Authorization of HIPAA disclosure (to be completed by dependent)


I understand that by granting this authorization, the person who obtains this information may disclose it to other individuals with or without my
consent and in so doing, the information would no longer be protected under HIPAA. I understand that my authorizing the use and disclosure of my
information is not a condition of enrollment in this health plan, eligibility for benefits or payment of claims.
Dependent’s name (please print) Date

Dependent’s signature Dependent’s date of birth (mm/dd/yyyy)

Note: If the person signing above is a personal representative of the named individual, attach copy of document granting authority to the
personal representative.

HealthEquity.com 866.346.5800
HIPAA_authorization_form_20190805

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