HIPAA authorizaon form
Mail or fax completed forms to:
Address: HealthEquity, An: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Fax: 801.727.1005
HealthEquity.com 866.346.5800
HIPAA_authorizaon_form_20190805
Authorizaon to disclose protected health informaon
Dependents must complete this form to authorize the disclosure of protected health informaon to the account holder.
Primary account holder informaon
Last name First name M.I.
Street address City State ZIP
Email address (required) Dayme phone
( )
SSN or HealthEquity ID number
HIPAA authorizaon (to be completed by dependent)
My protected health information is individually identifiable health information, including demographic information collected from me or created
or received by a health care provider, a health plan, my employer, or a health care clearinghouse, and relates to: (i) my past, present, or future
physical or mental health condition; (ii) the provision of the health care to me; or (iii) the past, present or future payment for the provision of
health care to me.
In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA), I, the undersigned, grant permission to
HealthEquity, Inc. to disclose protected health information (as defined in HIPAA) to the following person or persons:
Purpose of authorization:
c
At my request
c
Family member assisting with health care
c
Other:
Any limitations that I impose on HealthEquity with respect to this authorization are declared below:
This authorization will remain in effect for the duration of the state expiration requirement (may vary from 24-48 months) based off of primary
account holder’s state of residency. In addition, I may revoke this authorization at any time by notifying HealthEquity of the revocation in writing
and sending by fax to 801.727.1005, Attn: Member Services.
If at any time you need to alter this authorization form, please contact HealthEquity at 866.346.5800.
Authorizaon of HIPAA disclosure (to be completed by dependent)
I understand that by granng this authorizaon, the person who obtains this informaon may disclose it to other individuals with or without my
consent and in so doing, the informaon would no longer be protected under HIPAA. I understand that my authorizing the use and disclosure of my
informaon is not a condion of enrollment in this health plan, eligibility for benets or payment of claims.
Dependent’s name (please print) Date
Dependent’s signature Dependent’s date of birth (mm/dd/yyyy)
Note: If the person signing above is a personal representave of the named individual, aach copy of document granng authority to the
personal representave.
