HIPAA forms

Because Fallon Health is dedicated to protecting your privacy, we are strict about who can see your information. That's why we provide these forms for you to let us know how you want your information managed.

For our commercial members

Amendment Request for Personal Information form
This form is used to ask us to make changes to your record if you think it is inaccurate or incomplete. You do not need to use this form for corrections to your address, date of birth or name.

Authorization for Release of Personal Information form
This form authorizes Fallon Health to give your personal information to another individual or entity (such as your employer, if they are working on your behalf to resolve a claim issue).

Personal Representative Authorization form - Disclosing Personal Information
This form is for any Fallon Health member, except for MassHealth members, to give permission to Fallon to disclose your personal information to a designated person.

Personal Representative Authorization Form – Filing an Appeal
This form is only for Fallon Health's commercial plan members (for example, if you have Select Care, Direct Care, etc.) to give permission to someone else to file an appeal on your behalf.

For our MassHealth members

Personal Representative Authorization Form – Disclosing Personal Information
This form is only for Fallon MassHealth members to give permission to Fallon to disclose your personal information to a designated person.

Personal Representative Authorization Form – Filing an Appeal
This form is only for Fallon MassHealth members to give permission to someone else to file an appeal on your behalf.

For all members (as appropriate)

Veteran’s Office Authorization for Release of Personal Information form
This form gives Fallon Health permission to disclose your personal information to a veteran’s office.

Request for an Accounting of Disclosures of Personal Information form
This form is used to request a listing of who Fallon Health has shared your information with for reasons other than treatment, payment or health care operations. Please note there are limitations to the number of prior years you may request.

Restriction form
This form is used to put limitations on how we use or share your personal information.

For our Fallon Senior Plan and NaviCare members

For Fallon Senior Plan and NaviCare members, please visit the forms page for Fallon Senior Plan and the forms page for NaviCare.