HIPAA & PHI Forms
( Health Insurance Portability and Accountability Act of 1996 [HIPAA] )

The following is a list of Protected Health Information (PHI) notices and forms that can be requested from the Fund Office.

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Protected Health Information (PHI) Notices
Document Description
Information Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Delta Dental Information Privacy Notice This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Protected Health Information (PHI) Forms
Document Description
Request for Access to Protected Health Information (PHI) Form to request access to Protected Health Information maintained by the Cement Masons Health and Welfare Trust Fund for Northern California, Health & Welfare Plans, for the purpose of your inspection and/or obtaining copies.
Request for Amendment of Protected Health Information (PHI) Form to request an amendment of certain information in your Protected Health Information maintained by the Cement Masons Health and Welfare Trust Fund for Northern California, Health & Welfare Plans.
Request for Accounting of Disclosure of Protected Health Information (PHI) Form to request an accounting of certain disclosures of your Protected Health Information, which may have been made by the Plan or Business Associates of the Plan.
Request for Restriction of Protected Health Information (PHI) Form to request that certain portions of your Protected Health Information not be used or disclosed by the Cement Masons Health and Welfare Trust Fund for Northern California, Health & Welfare Plans, for Treatment, Payment, or Health Care Operations purposes.
Request for Confidential Communications of Protected Health Information (PHI) Form to request that all information relating to a certain Treatment, and to Payment for that Treatment, be sent to you only at a specified address.
Authorization for Use or Disclosure of Protected Health Information (PHI) Form to authorize the use or disclosure of certain parts of your Protected Health Information.