Fillable 2017 13a4 (U.S. Office of Personnel Management)

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2017 13a4 (U.S. Office of Personnel Management)

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U.S. OFFICE OF PERSONNEL MANAGEMENT
OFFICE OF THE INSPECTOR GENERAL
OFFICE OF INVESTIGATIONS
Exposure Request Form
Request Date:
Request Due Date:
Type of Request:
Response Time:
Delivery Method:
Data Format:
Is this request CONFIDENTIAL?**
**NOTE: Confidential Requests MUST NOT BE SHARED with Private Lines of Business, Local
Plans, or the Public. Contact the OIG Agent/Analyst before engaging in any investigative activities.
End Date:
Exposure Start Date:
Investigation Type:
Subject Information:
Summary Data Only (Total Billed/Paid Per Year)
Summary Data - 1 week response
Other
If Other, Please Specify:
OI – Standard Record Layout (flat file)
Yes
No
Other
If Other, Please Specify:
Name(s):
Location(s):
NPI(s):
TIN(s):
Other Identifier(s):
Benefits Type:
Carriers:
SFTP File Name:
OPM/OIG Case Number:
Requestor Contact Info:
Additional Information/
Special Requests:
OPM/OIG Case Name:
Medical (MD)
BlueCoss BlueShield (BCBS)
Aetna - HMO (AETN)
SAMBA Health (SAMB)
NALC Health Plan (NALC)
GEHA Health Plan (GEHA)
APWU Health Plan (APWU)
Kaiser Permanente (KPHP)
Univ. of Pitt Med Ctr (UPMC)
Other
Group Health Inc (EMBL)
Humana Health (HUMA)
*limited to 8 characters - no spaces or characters
*limited to 12 characters - no spaces -
does not have to match CLEAR case name
XXXX_EX__ _MD
Name:
Email:
Telephone:
Please provide a cover letter with total amount billed and paid.
We understand that the HIPAA Privacy Rule, 48 C.F.R. § 164.528, requires that you provide the individual with an accounting of certain disclosures of his or her
protected health information. You hereby are instructed under 48 C.F.R. § 164.528(a)(2)(i) to temporarily suspend the individual's right to receive an accounting of
this disclosure to the U.S. Office of Personnel Management's Inspector General, made under 48 C.F.R. § 164.512(d), for a period of three years because it is
believed that such an accounting to the individual would be reasonably likely to impede our activities.
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2017 13a4 (U.S. Office of Personnel Management)

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Completed 22 July 2020

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