WTA Benefit Trust
HIPPA Privacy Notice
Health Insurance Portability and Accountability Act of 1996 - a federal law affecting health care providers, hospitals/clinics, health insurance companies and benefit trust organizations
The final regulation, the Privacy Rule, was published December 28, 2000 (65 FR 82462.)
HIPAA addresses
by organizations subject to the Privacy Rule — called “covered entities,”
HIPAA assures
needed to provide and promote high quality health care and to protect the public's health and well being
HIPAA requires us to notify you of your privacy rights and places certain restrictions on sharing information even with family members.
Enrollment form: (ivory) In order to ensure that WTA Benefit Trust is in compliance with HIPAA, we need to update our enrollment information.
Acknowledgement Forms: We need to document that we have informed you and each person covered by your WTA Benefit Trust administrated benefits of the rights protected by HIPAA.
There is a form for
The parent/legal guardian may sign for children 17 and younger. Adults, including your adult children (18 and older) must each sign the appropriate form.
Patient Representative Forms. (white form) Although they are covered by your benefit, we may not discuss with you any claims for services for your spouse, domestic partner or adult child (18 and older) without that adult signing a Patient Representative Form.
The person filling out the Patient Representative Forms still retains the right to discuss his/her claims with the dental claims staff.
The parent/legal guardian is automatically the patient representative for his/her children 17 and under; therefore no Patient Representative Form is required. In the case of a step-parent or domestic partner who has not adopted the child or been designated by court as a legal guardian, the parent can sign a patient representative form on behalf of the child(ren) designating the other person to act as patient representative. (All children may be listed on one form.)
Note: You may designate anyone you wish to deal with claims -- the person does not have to be related by birth, marriage, or domestic partnership/
If you need more forms, please contact Wtahippa@hotmail.com
If you need additional forms, please contact wtahippa@hotmail.com or your building representative
To return the completed forms, please mail the forms back to the WTA Benefit Trust Office.
Your building representatives, other union officers and WTA Benefit Trust trustees may not take the forms, so please do not place the forms in their mailboxes.
WTA Benefit Trust HIPAA Policy and Procedures, Adopted Feb 2004 - You can print a hard copy.
You may also request a hard copy: wtahippa@hotmail.com
Privacy notice You can print a hard copy.
You may also request a hard copy: wtahippa@hotmail.com
Our current Privacy and Compliance Official is Connie Flood wtahippa@hotmail.com
18 year olds: When your child turns 18, we will send your child a privacy notice and acknowledgement form. If your child wishes for you to deal with his/her dental claims, we will need him/her to sign a personal representatives form. Please remember that your child must have turned 18 to sign the form.
The updated enrollment should allow us to mail out the forms shortly before your child's 18th birthday. If your child does not receive the information packet, you can request one by contacting wtahippa@hotmail.com
19 year olds: When your son or daughter turns 19, you will still need to submit the usual paperwork to qualify him/her for continuous coverage as a full time student. Please contact the Dental Benefits staff if you need assistance with this. 256-1234
The person filling out the Patient Representative Form still retains the right to discuss his/her claim with the dental claims staff.
The procedure to establish domestic partnership or guardian ship over children is not covered by HIPAA. For the spring 2004 updated enrollment, if you have previously provided the documentation to prove the legal relationship, you do not need to submit that documentation again.
After the spring 2004 updated enrollment or if you have any questions on this issue, you should contact the dental claims staff or a Benefit Trust trustee to determine the latest policy on providing documentation for
You can fill out a patient representative form giving us permission to discuss your claims with your spouse/domestic partner.
For children 17 and under
Both parents or legal guardians are automatically patient representatives, so there is no need for a form.
In the case of a step-parent or domestic partner who has not adopted the child or been designated by court as a legal guardian, the parent can sign a patient representative form on behalf of the child(ren) designating the other person to act as patient representative. (All children may be listed on one form.)
For children 18 and over
May designate both parents or any other adults that they wish to represent them in dealing with their claims.
Note: You may designate anyone you wish to deal with claims -- the person does not have to be related by birth, marriage, or domestic partnership.
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