HIPAA forms

Because Fallon Community Health Plan is dedicated to protecting your privacy, we are strict about who can see your information. In some cases, though, you might want to allow certain other people to see your information or perhaps get a copy for yourself. FCHP makes this easy for you to do by printing off the appropriate form below and submitting it according to the directions on the form.

Amendment Request for Personal Information form
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.

Authorization for Release of Personal Information form
Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).

Veteran’s Office Authorization for Release of Personal Information form
Allow a veteran’s office to receive your personal information from FCHP.

Personal Representative Authorization form
Identify a personal representative—someone FCHP can release your personal information to. Complete a form for each person you want to have as a representative.

Request for an Accounting of Disclosures of Personal Information form
Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.

Restriction form
Request a limit on how we use or share your personal information.