Free Wisconsin SeniorCare HIPAA Privacy Communication Request, HCF 13164 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13164 (Rev. 01/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN SENIORCARE

HIPAA PRIVACY ALTERNATE COMMUNICATION REQUEST
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHFS, as a covered entity, to implement processes that give patients certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of the information outlined on this form is mandatory. Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this purpose. INSTRUCTIONS: Mail this completed form to the following address: SeniorCare Customer Services PO Box 6710 Madison WI 53716-0710 SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial

SeniorCare Identification Number

Address Street, City, State, ZIP Code

Telephone Number ( )

SECTION II ALTERNATIVE COMMUNICATION REQUEST Please read the following and complete the information requested. You have the right to request how and where SeniorCare contacts you about your medical information. SeniorCare will accommodate reasonable requests if you provide a reasonable alternative means or location for communicating with you. To exercise this right, please complete this form. NOTE: SeniorCare does not routinely communicate protected health information to recipients, since SeniorCare does not provide the health care or treatment directly to you. Describe the protected health information you want subjected to alternative communication:

I request that SeniorCare communicate with me about my protected health information by the following alternative means. Provide full information on the alternative means you want used by SeniorCare:

I request that you communicate with me about my protected health information at the following alternative location. Provide full information on the alternative location:

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Wisconsin SeniorCare HIPAA Privacy Alternate Communication Request HCF 13164 (Rev. 01/05)

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SECTION III SIGNATURES Please sign the form and complete the appropriate information. SIGNATURE Recipient Date Signed

If this request is from a personal representative on behalf of the recipient, provide a copy of the documentation to support the representation and complete the following: Name Personal Representative Relationship to Recipient

SIGNATURE Personal Representative

Date Signed