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Health Insurance Portability and Accountability Act of 1996 (HIPAA)


HIPAA and You

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996. According to Medicare, "the Standard for Privacy of Individually Identifiable Health Information (also called the 'Privacy Rule') of HIPPA makes sure your health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being".

ONECare by Care1st Health Plan Arizona, Inc (HMO SNP) ("ONECare"). has taken the necessary safeguards to protect your PHI and has developed policies and provided training on the issue to assist our staff. ONECare also offers HIPAA-related resources to doctors and other providers who are involved in your health care. We will keep you informed of our continued HIPAA efforts.


HIPAA Authorization to Release Record of Protected Health Information (PHI)

Authorization to Share Personal Health Information

Appointment of Representative Form (CMS-1696)

An appointed representative is a person who can act on your behalf to request:

  1. An appeal; and/ or
  2. Grievance/ Complaint; or
  3. an organization determination/authorization

This person can be a relative, friend, advocate, or anyone else you trust to act on your behalf. If you want to appoint someone to act for you regarding an appeal, grievance/complaint and/or an organization determination/authorization, then both you and the person you assign has to sign and date this statement that gives your assigned person legal permission to act as your appointed representative. Please note that your doctor or other prescriber is not required to submit this form or other equivalent notice.

You can use this form, OR you can make your own statement (an equivalent written notice) as long as it contains all the required information.

The required information of an 'equivalent written notice' is one that:

A completed AOR is

Request for an Accounting Disclosure

Privacy Practices Complaint

If you want to lodge a complaint about our privacy practices, please let us know. You are not required to fill out this form in order to file a privacy practices complaint. You may file by calling our Member Services Department. Click here to locate our Privacy Practices, which offers additional information on ways to file a privacy complaint.

Request for an Amendment of PHI

Please fill out this form if you believe there is a mistake in your PHI or that important information is missing and you are requesting that we correct or add to the record.

Request for Confidential Communications

You may request us to send your protected health information (PHI) to you at an alternative location (for example, your work address) or by a different means (for example, via fax instead of regular mail). To do so, you must complete this form and return it to ONECare at the address provided in the document. If the cost of meeting your request involves more than a reasonable amount, we are permitted to charge you our costs that exceed that amount.

Request to Limit Uses and Disclosure of PHI

You can tell ONECare what information you do not want to share and who you don't want us to share your information with. We will review and consider your request. ONECare is not required to agree with your request. If we don't agree with your request we will let you know.


Click here to read more information on doing your part in preventing health care identity theft, including fraud, waste and abuse!

HIPAA Resources

U.S. Department of Health & Human Services' Office of Civil Rights (OCR)

Answers to Frequently Asked Questions, additional HIPAA information, including HIPAA-related laws, regulations, and enforcement - Click Here or call OCR's toll-free number at: 1-866-627-7748.


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H5430_18_024_MK CMS Approved Pending

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