Health Insurance Portability and Accountability Act of 1996

Among the fundamental principles of the privacy rule enunciated under HIPAA are the rights of individuals regarding their personal health information. These rights include:

  • The right to adequate notice of the uses and disclosures of protected health information (PHI) that a covered entity may have made (C.F.R. 164.520). Contact your employer for a copy of your health plan’s PHI notice.
  • The right to request (but not necessarily be granted) restrictions on the uses and disclosure of PHI (C.F.R. 164.522)
  • The right to access PHI (C.F.R. 164.524)
  • The right to amend PHI (C.F.R. 164.526)
  • The right to an accounting of certain disclosures (C.F.R. 164.528)

To assist our clients with their efforts in complying with the HIPPA Privacy Regulations, CenBen USA, Inc. has developed several forms for individuals who wish to exercise one of their rights under HIPAA.

The first step for anyone desiring to exercise a HIPAA right is to contact our Customer Service department using the toll free number provided on his or her identification card. In most cases a Customer Service Representative will be able to assist the individual without the need for filing a formal HIPAA right request. However, if after discussing your need with a Customer Service Representative you desire to submit a formal HIPPA request, click on the appropriate link below to obtain the form needed to submit your request.

Authorization Form
Access Request Form
Amendment Request Form
Confidential Communication Request Form
Disclosure Accounting Request Form
Restriction Request Form
Revocation of Authorization Form
Personal Representative

All of these documents are in PDF format, which requires the Adobe Acrobat Reader. If you do not have an Acrobat Reader, you can download it from Adobe’s site, click here.