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).
Checking the box and entering your name below acts as your digital signature:
Mail or e-mail supporting documentation, if applicable to:
- 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