Form CMS-10428 Pre-Existing Condition Insurance Plan (PCIP) HIPAA Autho

PCIP Authorization to Share Personal Health Information
Use this form if you want the Federally-run PCIP to share your personal health information with other
people or organizations who call PCIP on your behalf. The Federally-run PCIP is operated by the U.S.
Department of Agriculture’s National Finance Center, other Federal agencies, and GEHA, the PCIP
benefits administrator.
1. Print Name
(first & last name of PCIP applicant/enrollee)

PCIP Account Number or
PCIP ID Number (if known)

Date of Birth
(mm/dd/yyyy)

2. PCIP will only share the personal health information you agree to.

2A: Check one box below to tell us the specific information you agree to share:
 Limited Information (go to question 2B)
 Any Personal Health Information that PCIP has about me (go to question 3)
2B: If you selected "Limited Information," check which types of information you agree to
share:
 Information about your PCIP eligibility
 Information about your PCIP claims
 Information about your PCIP enrollment
 Information about premium payments
 Other specific information (please write below; for example, “ payment information”)

3. Check one box below to let PCIP know how long you agree to share your personal
health information. (Subject to applicable law —for example, your State may limit how

long PCIP can share your personal health information.)
 Share my personal health information two years following my disenrollment from
PCIP.
 Share my personal health information for a limited period only:
beginning : ______________ and ending : _______________
(mm/dd/yyyy)

(mm/dd/yyyy)

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4. List the names and addresses of the people or organizations you want PCIP to share
your personal health information with. Please provide the specific name of the person for

any organization you list:
1. Name:
Relationship or Organization:
Address:
2. Name:
Relationship or Organization:
Address:
3. Name:
Relationship or Organization:
Address:
5. I give PCIP permission to share my personal health information listed on
page 1 with the person(s) or organization(s) named above. I understand that my

personal health information may be re-disclosed by the person(s) or organization(s) and
may no longer be protected by law.
_______________________________________________________________________________________________

Signature

Phone Number

Date

(mm/dd/yyyy)

PCIP Applicant/Enrollee Address (Street, City, State & ZIP)

Are you completing this form for someone else?

 Check here if you’re signing as a personal representative, and complete below. Unless
you’re the parent of a minor child, please attach documented proof that you’re acting on
that person’s behalf (for example, Power of Attorney).
Address of Person Completing Form (Street, City, State & ZIP)

Phone Number:
Relationship to Applicant/Enrollee:

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February 2012

6. Send this ORIGINAL completed, signed form to:
PCIP
Attn: Compliance Dept.
P.O. Box 438
Independence, MO 64051-0438

7. NOTE: You Can Stop Information-Sharing at Any Time

You have the right to stop sharing your personal information at any time, although this
won’t affect any information that PCIP has already shared. To end your permission, send
a written request to the address shown above.
PCIP won’t base your treatment, payment, enrollment, or benefit eligibility on
whether or not you sign this form.

According to the Paperwork Reduction Act of 1995, you don’t need to answer the questions on this form unless it displays a
valid OMB control number. The valid OMB control number for this form is [Insert OMB Form Number]. We estimate it will
take an average o f 15 minutes to complete this form, including the time to read instructions, gather information, and answer
the questions. If you have comments about the accuracy of this time estimate or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
21244-1850.

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February 2012