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

PCIP Authorization to Share Personal Health Information

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.
Use this form if you want the Federally-run PCIP to share your personal health information with other people
Department
ofPCIP
Agriculture’s
National
Finance Center,
Federalbyagencies,
and GEHA,ofthe PCIP
or organizations
who call
on your behalf.
The Federally-run
PCIPother
is operated
the U.S. Department
benefits
administrator.
Agriculture’s
Agriculture’
s National
Finance Center,
Center, other Federal agencies, and GEHA, the PCIP benefits administrator.
administrator.

1. Your information.
1. Print Name

PCIP Account Number or
PCIP ID Number (if known)

last name
of PCIP
applicant/enrollee)
Print Name (first &(first
last &
name
of PCIP
applicant/enrollee)

2. PCIP
will
share
the
PCIP Account Number
or PCIP
ID only
Number
(if known)

Date of Birth
(mm/dd/yyyy)

personal health information you
Dateagree
of Birthto.
(mm/dd/yyyy)

2A: Check one box below to tell us the specific information you agree to share:

2. PCIP will only share
the Information
personal health
information
you agree to.
2B)
Limited
(go to question
2A: Check one box below to tell us the specific information you agree to share:

Any Personal Health Information that PCIP has about me (go to question 3)

Limited Information (go to question 2B)

2B: If you selected "Limited Information," check which types of information you agree to
share:

Any Personal Health Information that PCIP has about me (go to question 3)

Information
about
yourwhich
PCIPtypes
eligibility
2B: If you selected “Limited
Information,”
check
of information you agree to share:

about your
Information aboutInformation
your PCIP eligibility

about
Information aboutInformation
your PCIP claims

PCIP claims

your PCIP enrollment

about premium
payments
Information aboutInformation
your PCIP enrollment

specific
information
Information aboutOther
premium
payments

(please write below; for example, “payment information”)

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

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

Share my personal health
information two years following my disenrollment from PCIP.
PCIP.
Share my personal health information for a limited period only:

Share my personal health information for a limited period only:

beginning: ______________ and ending: ______________
(mm/dd/yyyy)
(mm/dd/yyyy)
and
beginning : ______________
(mm/dd/yyyy)

ending : _______________
(mm/dd/yyyy)

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PCIP Authorization to Share Personal Health Information

February 2012

1

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

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.
PCIP Authorization to Share Personal Health Information

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Privacy Act and Paperwork Reduction Notice
Section 1101 of the Patient Protection and Affordable Care Act, Public Law 111-148, authorizes us to collect the
information on this form. The information you provide will allow the United States Department of Health and
Human Services through the United States Department of Agriculture’s National Finance Center, other Federal
agencies, and the PCIP benefits administrator, Government Employees Health Association, to disclose information,
with respect to the status of an application, enrollment, premium billing or claim, to individuals or organizations
of your choosing. If you don’t provide this information, we won’t be able to disclose information about your
application, enrollment, premium billing or claim without your prior authorization.
Paperwork Reduction Act Statement. This information collection meets the requirements of 44 United States
Code §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these
questions unless we display a valid Office of Management and Budget control number. The valid OMB control
number for this information collection is 0938-1161. We estimate that it will take about fifteen minutes to read
the form, gather the facts, and answer the questions.
You may send comments on our time estimate to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Send only comments relating to our time estimate to
this address, not your form.

PCIP Authorization to Share Personal Health Information

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