Home / Members / Confidential / Alternate Communication Request Form Confidential / Alternate Communication Request Form 1 Enter Information 2 Review Details 3 Submit Date Individual/Member Name Please enter a Individual/Member Name. Individual/Member Date of Birth Format: MM/DD/YYYY Please enter a Individual/Member Date of Birth. Individual/Member ID Number Please enter a Individual/Member ID Number. I request that CHIPA send my confidential protected health information (PHI) to an alternate address and/or use an alternate method to contact me. Alternate Contact Information: I request that my PHI be mailed to: Name Please enter a Name. Address Please enter an Address. City Please enter a City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip Please enter a Zip. I request that my PHI be emailed to: E-mail Address 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 I request that calls are made to: Telephone Number 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 I request that CHIPA send my confidential protected health information (PHI) to the main address on record, revoking the prior request to send my PHI to an alternate address. Revoke the following contact information: Contact and Mailing Address: Name Please enter a Name. Address Please enter an Address. City Please enter a City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip Please enter a Zip. E-mail Address: E-mail Address Please enter an E-mail Address. Telephone Number: Telephone Number Please enter an Telephone Number. CHIPA may contact me, as needed, at this 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 Choose file Attachment 2 Choose file Attachment 3 Choose file Attachment 4 Choose file Attachment 5 Choose file Checking the box and entering your name below acts as your digital signature: I, the Requestor, confirm that all details and selections above are accurate and I consent to have my information processed as requested.* Name of Requestor: 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. Date Individual/Member Name Please enter a Individual/Member Name. Individual/Member Date of Birth Format: MM/DD/YYYY Please enter a Individual/Member Date of Birth. Individual/Member ID Number Please enter a Individual/Member ID Number. I request that CHIPA send my confidential protected health information (PHI) to an alternate address and/or use an alternate method to contact me. Alternate Contact Information: I request that my PHI be mailed to: Name Please enter a Name. Address Please enter an Address. City Please enter a City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip Please enter a Zip. I request that my PHI be emailed to: E-mail Address 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 I request that calls are made to: Telephone Number 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 I request that CHIPA send my confidential protected health information (PHI) to the main address on record, revoking the prior request to send my PHI to an alternate address. Revoke the following contact information: Contact and Mailing Address: Name Please enter a Name. Address Please enter an Address. City Please enter a City. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Please enter a State. Zip Please enter a Zip. E-mail Address: E-mail Address Please enter an E-mail Address. Telephone Number: Telephone Number Please enter an Telephone Number. CHIPA may contact me, as needed, at this 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: I, the Requestor, confirm that all details and selections above are accurate and I consent to have my information processed as requested. Name of Requestor: 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 complete the reCAPTCHA challenge field above. Your form was successfully completed.Requests will be completed within 7 calendar days.Submit another entry Your submission failed.Please check your entry and try again. If you continue to receive this error, please contact support.
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