Member Designated Representative Form



Policyholder Designated Representative Form

Your personal health information is confidential. As permitted by the requirements of the Health Insurance Portability and Accountability Act (“HIPAA”), your completion of the attached Policyholder Designated Representative Form permits a Coventry Health Care plan* (“Coventry”), and its subcontractors, to provide your personal health information to the person(s) you name on the form. For instance, you may want to designate your spouse, your broker, a family Policyholder or a friend to assist you with your health care benefits. This form does not permit the Coventry Health Care plan, or its subcontractors, to release information to anyone except the individual or entity you name on the attached form.

Coventry will NOT release information pertaining to HIV/AIDS, alcohol or substance abuse treatment or mental health treatment (all which by law, may require a special form for release), even if a specific claim or authorization question from the person named below is raised, unless you specifically authorize the release of such information, by completing Section 2 of the Policyholder Designated Representative Form and completing the Authorization to Use or Disclose Form.

*Note: “Coventry Health Care”, Inc. and its licensed affiliated companies, including, but not limited to, Altius Health Plans, Inc.; Cambridge Life Insurance Company; Carelink Health Plans, Inc.; Coventry Health Care of Delaware, Inc.; Coventry Health Care of Georgia, Inc.; Coventry Health Care of Iowa, Inc.; Coventry Health Care of Nebraska, Inc.; Coventry Health Care of Pennsylvania, Inc.; Coventry Health Care of Louisiana, Inc.; Coventry Health and Life Insurance Company; Coventry Health Care of Kansas, Inc.; Coventry Health Care National Accounts, Inc.; First Health Life & Health Insurance Company; First Health Services Corp.; Group Health Plan, Inc.; HealthAmerica Pennsylvania, Inc., HealthAssurance Pennsylvania, Inc., HealthCare USA of Missouri, L.L.C.; OmniCare Health Plan, Inc.; PersonalCare Insurance of Illinois, Inc.; Southern Health Services, Inc.; Coventry Health Care of Florida, Inc., Coventry Health Plan of Florida, Inc., Coventry Health and Life Insurance Company, Coventry Summit Health Plan, Inc., and WellPath Select, Inc.

Policyholder Designated Representative Form

SECTION 1: Designated Representative – General

As permitted by the Health Insurance Portability and Accountability Act (“HIPAA”), I hereby designate the person named below to receive my personal health information, including, but not limited to, procedures, and treating providers, from the Coventry Health Care plan (“Coventry”) and its subcontractors, for purposes of assisting with or facilitating my health care benefits. I understand that this information may include Protected Health Information and other information protected by HIPAA and other laws.

SECTION 2: Designated Representative – Mental Health, Substance Abuse and HIV

Yes / No If yes, you must also complete the Authorization to Use or Disclose Form

I understand and agree that:

➢ Coventry and its subcontractors may share my personal health information with the person(s) listed below.

➢ This authorization does not provide my Designated Representative with any authority over any treatment or direct-care decisions.

➢ Once released to my Designated Representative, my personal health information may no longer be protected by those laws, and my Designated Representative could share my personal health information with others.

➢ I am not required to complete this form and my information will not be shared with the Designated Representative unless I sign this form.

➢ This designation will be effective until the termination of my NECHIP coverage or until I notify Coventry otherwise.

➢ I may change or cancel this request at anytime by sending my change in writing to the address below.

➢ By signing this form, I release Coventry and its subcontractors from any liability of any nature in connection with its release of my personal health information to the person(s) designated below and any use, misuse or secondary release of such information by the person(s) named below.

I have fully read this Form and hereby designate the person listed below as my Designated Representative.

Policyholder Name: ____________________________________________________________________________

Coventry Health and Life Insurance Company Policyholder ID Number: __________________________________

Policyholder Signature*: _______________________________________ Date: __________________________

*If someone other than the Policyholder is signing this form (e.g., a legal guardian), please provide your relationship to the Policyholder and attach any appropriate documentation of authority.

Designated Representative Information:

Designee Name: __________________________________ Phone:______________________________

Designee Address: _________________________________ Relationship to Policyholder:________________

City, State, Zip Code:________________________________________________________________________

Mail completed form to:

Coventry Health Care of Nebraska, Inc.

P.O. Box 7705

London, KY 40742

Please keep a copy of this form for your records

AUTHORIZATION TO USE OR DISCLOSE

Section I

I authorize Coventry Health and Life Insurance Company and its subcontractors, and/or ____________________ (provider/additional party name) to use or share the following information: ___________________________________________________________________________________________

___________________________________________________________________________________________.

I specifically authorize the release of confidential information relating to: (please check “Yes” or “No” for each item below):

Yes /  No HIV/AIDS-related information, diagnosis and test results

Yes /  No Mental Health Information

Yes /  No Substance Abuse Information

This information will be used for: _______________________________________________________________

___________________________________________________________________________________________.

The name and address of the individual or organization this information may be shared with:

Party One Party Two (if more than two parties use additional release)

Name: ___________________________________ Name: _________________________________________

Address: __________________________________ Address: _______________________________________

Attention: _________________________________ Attention: ______________________________________

Ending Date or Event (not to exceed 24 months from the date signed below): ___________________________ or ( One year from the date signed below.

Section II I understand that:

• I may be charged a reasonable fee for copying, depending on the number of records.

• I have the right to look at the information that is being shared.

• Third parties who receive this information could share it with others.

• I have the right to refuse to sign this form. If I do not sign this form, Coventry Health and Life Insurance Company and its subcontractors, may not share this information for the purposes above.

• I may revoke this Authorization at any time by writing to Coventry Health and Life Insurance Company and its subcontractors, may share information based on having this Authorization until written notification is received revoking this authorization.

______________________________________________________________________ ________________

Policyholder’s Signature (or signature of legal representative/parent/guardian) Date

If signed by personal representative, describe authority and attach a copy of the appropriate legal document granting such authority.

The following information must be provided to identify the Policyholder:

Policyholder Name: ______________________________________________________________________________

First Name MI Last Name

Policyholder ID #: ______________________________ Policyholder Date of Birth: __________________________

(From NECHIP ID Card) (mm/dd/yyyy)

Please keep a copy of this authorization for your records.

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