What is HIPAA?
The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996. The purpose of this law is to establish national standards to protect individuals’ personally identifiable information and to set out rules for all those who may access this information. We have you review and sign this form annually so you know what kind of data will be collected, who might have access to it, and how it will be disclosed while we assist you in enrolling in health insurance and participating in the Healthcare Cost Assistance Program.
1. WHAT MAY BE COLLECTED AND/OR DISCLOSED?
All information provided on your application for health insurance and/or enrollment is considered your protected health information, whether via website enrollment, direct enrollment, phone enrollment, or on paper, including information on all members of your tax filing household, and all past, present, and future periods of health care information (as defined by HIPAA).
2. WHO IS AUTHORIZED TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION?
There are several partners who work together to ensure the Healthcare Cost Assistance Program Benefits are administered successfully. As licensed insurance agents, Valley Insurance Professionals, Inc. may collect your protected health information through the process of assisting you or your family to apply for health insurance. Your protected health information may be disclosed/shared between Valley Insurance Professionals, RISE Partnership (also known as “Carewell SEIU 503”), the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers, as well as with any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier, as necessary to apply for, renew or service your insurance coverage, and/or administer your benefits for the Healthcare Cost Assistance Program.
3. WHAT IS THE PURPOSE OF THE USE OR DISCLOSURE OF MY INFORMATION?
Your information may be used or disclosed to assist RISE Partnership (also known as “Carewell SEIU 503”), the Oregon Homecare Workers Supplemental Trust and the Oregon Homecare Workers Benefit Trust in the administration of your benefits under the applicable Trusts.
4. HOW LONG IS THIS AUTHORIZATION VALID?
This Authorization Form is valid beginning the date of this Agreement and expires ten (10) years from the date of execution of this Authorization Form.
5. ACKNOWLEDGMENT
I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it, subject to the federal privacy regulation. I have the right to refuse to sign this Authorization Form; however, I understand my refusal may impact my ability to obtain Healthcare Cost Assistance. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I further understand that if I have a spouse, child(ren) or other members of my tax filing household listed on my application for health insurance, their personally identifiable information (PII) may also be disclosed to the entities listed above. I acknowledge that I have informed my spouse, child(ren) or other members of my tax filing household of this disclosure.