Confidential / Alternate Communication Request Form

1 Enter Information
2 Review Details
3 Submit

Please enter a Individual/Member Name.
Format: MM/DD/YYYY
Please enter a Individual/Member Date of Birth.
Please enter a Individual/Member ID Number.

Alternate Contact Information:


Please enter a Name.
Please enter an Address.
Please enter a City.
Please enter a State.
Please enter a Zip.
Please enter an E-mail Address.

Note: Information that is sent out automatically by our systems cannot be emailed and will be sent to the mailing address provided

Please enter an Telephone Number.

Note: Information that is sent out automatically by our systems cannot be emailed and will be sent to the mailing address provided


Revoke the following contact information:


Please enter a Name.
Please enter an Address.
Please enter a City.
Please enter a State.
Please enter a Zip.
Please enter an E-mail Address.
Please enter an Telephone Number.

Please enter a Telephone Number.

Please be aware:

  • Reimbursement of behavioral healthcare services is issued to the subscriber (when the dependent is under the age of twelve (12)) or provider of services only. All requests to change this must include an explanation of why payment should be made to someone other than the subscriber.
  • All claims submitted that require reimbursement to someone other than the subscriber (when the dependent is under the age of twelve (12)) must be accompanied with proof of payment (i.e., cancelled check or the provider’s receipt of payment with the payer identified).
  • I understand that CHIPA will use the above alternate communication information until I change this request. I understand that I may change or revoke this request at anytime by completing another Confidential/Alternative Request Form.

If you are requesting a confidential communication change on behalf of someone other than yourself, please enclose proof of your authority to do so (i.e., guardianship order, custody order, court order).


Supporting Documentation:

Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5

Checking the box and entering your name below acts as your digital signature:

Please enter the Requestor Name.

Mail or e-mail supporting documentation, if applicable to:

CHIPA
Clinical Operations
PO Box 6065
Cypress, CA 90630-0065

E-mail: CAAlternateCommunicationRequests@beaconhealthoptions.com


Definitions

  • Individual/member: the person who is the subject of the protected health information
  • Legally Authorized Representative: someone who has the legal authority to act on an individual’s behalf in order to make decisions about that person’s health care. Parents may be personal representatives for minors, except those minors who have been given the legal freedom to act on their own. Personal representatives may include guardians, conservators and other persons who have been given legal responsibility for another individual. Federal law, state law and the specific terms of the appointment determine the authority granted to the personal representative.
  • Member identification number: the number assigned to an individual by a health plan; sometimes it is the individual’s social security number

PLEASE REVIEW YOUR INFORMATION BEFORE SUBMISSION.

Use Previous button at the bottom of the form to go back and make revisions. Otherwise click Submit to finalize your submission.


Please enter a Individual/Member Name.
Format: MM/DD/YYYY
Please enter a Individual/Member Date of Birth.
Please enter a Individual/Member ID Number.

Alternate Contact Information:


Please enter a Name.
Please enter an Address.
Please enter a City.
Please enter a State.
Please enter a Zip.
Please enter an E-mail Address.

Note: Information that is sent out automatically by our systems cannot be emailed and will be sent to the mailing address provided

Please enter an Telephone Number.

Note: Information that is sent out automatically by our systems cannot be emailed and will be sent to the mailing address provided


Revoke the following contact information:


Please enter a Name.
Please enter an Address.
Please enter a City.
Please enter a State.
Please enter a Zip.
Please enter an E-mail Address.
Please enter an Telephone Number.

Please enter a Telephone Number.

Please be aware:

  • Reimbursement of behavioral healthcare services is issued to the subscriber (when the dependent is under the age of twelve (12)) or provider of services only. All requests to change this must include an explanation of why payment should be made to someone other than the subscriber.
  • All claims submitted that require reimbursement to someone other than the subscriber (when the dependent is under the age of twelve (12)) must be accompanied with proof of payment (i.e., cancelled check or the provider’s receipt of payment with the payer identified).
  • I understand that CHIPA will use the above alternate communication information until I change this request. I understand that I may change or revoke this request at anytime by completing another Confidential/Alternative Request Form.

If you are requesting a confidential communication change on behalf of someone other than yourself, please enclose proof of your authority to do so (i.e., guardianship order, custody order, court order).


Supporting Documentation:

Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5

Checking the box and entering your name below acts as your digital signature:

Please enter the Requestor Name.

Mail or e-mail supporting documentation, if applicable to:

CHIPA
Clinical Operations
PO Box 6065
Cypress, CA 90630-0065

E-mail: CAAlternateCommunicationRequests@beaconhealthoptions.com


Definitions

  • Individual/member: the person who is the subject of the protected health information
  • Legally Authorized Representative: someone who has the legal authority to act on an individual’s behalf in order to make decisions about that person’s health care. Parents may be personal representatives for minors, except those minors who have been given the legal freedom to act on their own. Personal representatives may include guardians, conservators and other persons who have been given legal responsibility for another individual. Federal law, state law and the specific terms of the appointment determine the authority granted to the personal representative.
  • Member identification number: the number assigned to an individual by a health plan; sometimes it is the individual’s social security number