Privacy materials
All of the forms listed below are in PDF format, which allows you to view them electronically on most computers. The Adobe Acrobat® reader is required to view and print PDF files. If you do not have the reader, click to download Adobe Acrobat for free.
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PCIP Health Plan Notice of Privacy Practices
The PCIP Health Plan Notice of Privacy Practices is provided to you as required by the Health Insurance Portability and Accountability Act (HIPAA) to describe how medical information about you may be used and disclosed and how you can get access to this information.
Authorization Form
PCIP enrollees may use this form to allow PCIP to disclose protected health information to a designated person.
Revocation of Authorization Form
PCIP enrollees may use this form to revoke or remove an authorization for disclosure of protected health information.
Confidential Communications Form
PCIP enrollees may use this form to make a reasonable request to receive communications by an alternative means or at an alternative location, if disclosure of all or part of that information could endanger the individual.
Revocation of Confidential Communications Form
PCIP enrollees may use this form to revoke or remove a previously accepted confidential communication.
Request for Restriction Form
PCIP enrollees may use this form to request restriction of their protected health information from disclosure to a specified person(s).
Revocation of Restriction Form
PCIP enrollees may use this form to revoke or remove a previously accepted restriction of their protected health information from disclosure to a specified person(s).
Access Form
PCIP enrollees may use this form to request copies of health information.
Accounting of Disclosures Form
PCIP enrollees may use this form to request an accounting of disclosures regarding their protected health information.
Amendment Form
PCIP enrollees may use this form to request an amendment of their protected health information.
Privacy and/or Security Complaint Form
This form may be used by anyone to report a breach of privacy and/or security in regard to the PCIP health plan.
