Manage Private Information (HIPAA)
Authorization For Disclosure OR Request For Access To Protected Health Information
This form must be completed to allow Braven Health to disclose protected health information regarding one of its members to a third party.
ID: #40010 (0922)
Request for Access to Private Information Form
Use this form to request access to your private information (PI) held by Braven Health and its business associates.
ID: #40017 (0922)
Request for Amendment of Private Information
Use this form to request a change to your records held by Braven Health, and its business associates.
ID: #40019 (0922)
Request for Confidential Communications
Use this form to request communication of your private information by Braven Health and its business associates to be sent to an alternative location or as otherwise agreed.
ID: #40016 (0922)
Request for Termination of Confidential Communications
Use this form to request termination of confidential communication of my private information by Braven Health and its business associates.
ID: #40015 (0922)
Request for Appointment of Legal Personal Representative for Member
Use this form to let another person handle your health care needs which includes full access to your personal health information, changes to your health care coverage, as well as receiving your health care mail.
ID: #40014 (0922)
Request to Terminate an Appointed Legal or Limited Personal Representative
This form must be completed when a member wishes to terminate an appointed legal or limited personal representative.
ID: #40013 (0922)
Solicitud de nombramiento de representante personal legal para un asegurado
Utilice este formulario para dejar que otra persona maneje sus necesidades de salud, lo que incluye permitir el acceso completo a su información personal de salud, cambios en su cobertura de salud, así como también recibir su correo de salud médica.
ID: #40011 (0922)
Request for Appointment of Limited Personal Representative for Member
Use this form if you wish to allow your personal health information to be disclosed to the person named below so they can assist you with your health care and payment for health care. This person will not be permitted to make policy changes.
ID: #40008 (0922)
Solicitud de nombramiento de representante personal limitado para un asegurado
Utilice este formulario si desea permitir que su información de salud personal sea divulgada a la persona nombrada abajo para que pueda ayudarlo con su informacion personal de salud y el pago de la atención médica. Esta persona no podrá realizar cambios en la póliza.
ID: #40009 (0922)
Request For Accounting Of Disclosures
This form must be completed when a member wants to request an accounting of disclosures of private information made by Braven Health. These will not include disclosures of private information made for purposes of treatment, payment or healthcare operations, disclosures to the member to whom the private information pertains, disclosures to a personal representative of the member, or as stipulated by federal or state privacy laws.
ID: #40012 (0922)
Appointment of Representative Form
Use this form to request that Braven Health accept requests for coverage, grievances, and appeals from a representative. The form must be signed and dated by both the member and the representative. A completed form is valid for one (1) calendar year following the signature date on the form.