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HIPAA & PHI Forms

The following is a list of HIPAA & PHI forms that can be requested from the Fund Office.

Some of the plan documents may be available for online viewing in the PDF file format. Adobe's Acrobat Reader® is required.

If you do not have Adobe’s Acrobat Reader® installed on your computer, click here to go to the Adobe website to download and install the most recent version.

If you would like the document mailed to you:

  1. Select the checkbox next to the document’s name (you can select as many different documents as you like).
  2. Once your selections are made, scroll down this page and comlete your personal information.
  3. When ready to send your request, click the Submit button to automatically send the Email request to our Customer Service section.
Protected Health Information (PHI) Notices
Document
Description
In-Mail Request
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Protected Health Information (PHI) Forms
Document
Description
In-Mail Request
Form to request access to Protected Health Information maintained by the Laborers Health and Welfare Trust Fund for Northern California, Health & Welfare Plans, for the purpose of your inspection and/or obtaining copies.
Form to request an amendment of certain information in your Protected Health Information maintained by the Laborers Health and Welfare Trust Fund for Northern California, Health & Welfare Plans.
Form to request an accounting of certain disclosures of your Protected Health Information, which may have been made by the Plan or Business Associates of the Plan.
Form to request that certain portions of your Protected Health Information not be used or disclosed by the Laborers Health and Welfare Trust Fund for Northern California, Health & Welfare Plans, for Treatment, Payment, or Health Care Operations purposes.
Form to request that all information relating to a certain Treatment, and to Payment for that Treatment, be sent to you only at a specified address.
Form to authorize the use or disclosure of certain parts of your Protected Health Information.


Personal Information
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Name*
  
Health Plan ID
  
Address 1*
  
Address 2
  
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Email Address
  
Telephone Number
  
TeleFAX Number
  

 
Copyright ©2003; Laborers Funds Administrative Office of Northern California, Inc. All rights reserved.
Derechos Reservados Propiedad Literaria ©2003, La Oficina Administrativa de Fondos de los Obreros del Norte de California, Inc.