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HIPAA Forms

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was enacted to protect the continuation of healthcare coverage for employees. It provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs. Through HIPAA, national standards and an enforcement mechanism have been set for electronic transactions related to protected health information (PHI); industry-wide standards for healthcare information on electronic billing and other processes are mandated; and healthcare fraud and abuse has been reduced.

EHIM provides a number of HIPAA-related forms for groups and their members to manage PHI. The following forms are available for download and can be faxed or mailed back to EHIM once they have been completed. Please note that all forms are available in Portable Document Format (PDF) and require a PDF reader to be opened. The most recent PDF reader is available through the Adobe website.

Request for Amendment of Protected Health Information

Authorization to Use and/or Disclose Protected Health Information

Request for Access to Designated Record Set

Request for Accounting of Disclosures of Protected Health Information

Designation of Personal Representative

Request for Restriction of Personal Health Information

Revocation of Authorization to Use and/or Disclose Protected Health Information

Questions and Complaints

If you are concerned that we may have violated your privacy rights, or you believe we have inappropriately used or disclosed your PHI, please call us at (248) 948-9900.

You also may submit a written complaint to the U.S. Department of Health and Human Services in its Office of Civil Rights (“OCR”). Complaints must be in writing, either paper or electronically, must name the entity (plan), describe the acts or omissions you believe to be in violation of the HIPAA privacy rules and be filed within 180 days of the date you knew or should have known the act or omission occurred, unless the OCR waived the time limit for good cause shown.  You may file a written complaint to the Secretary by mail, fax or e-mail as provided below.  You may, but are not required to, use the OCR’s Health Information Privacy Complaint Form. To obtain a copy of this form or for additional information about the HIPAA privacy rules or how to file a complaint with the OCR, you should contact any OCR office or go to http://www.hhs.gov/ocr/hipaa.

You have the right to file a complaint if you believe that we have violated your rights. There can be no retaliation against you for making a complaint. You can file the complaint with us directly. Complaints also may be filed by e-mail to OCRComplaint@hhs.gov. Written complaints may be filed at the appropriate OCR office.

If you want more information about our privacy practices, or a written copy of this notice, please contact our Privacy Officer at the address or telephone number listed below:

Attn: Privacy Officer
Employee Health Insurance Management, Inc.
26711 Northwestern Hwy, Suite 400
Southfield, MI 48033
Telephone Number: (248) 948-9900