HIPAA forms

Because Fallon Community Health Plan is dedicated to protecting your privacy, we are strict about who can see your information. In some cases, though, you might want to allow certain other people to see your information or perhaps get a copy for yourself. FCHP makes this easy for you to do by printing off the appropriate form below and submitting it according to the directions on the form.

Amendment Request for Personal Information form 
Request changes to your record if you think it is inaccurate or incomplete. This form is not required for corrections to your address, date of birth or name.

Authorization for Release of Personal Information form 
Allow another individual/entity to receive your personal information from FCHP (such as your employer, if they are working on your behalf to resolve a claim issue).

Veteran’s Office Authorization for Release of Personal Information form 
Allow a veteran’s office to receive your personal information from FCHP.

Personal Representative Authorization form - Disclosing Personal Information 
This form is to be used by any FCHP member, other than MassHealth members, to authorize FCHP to disclose his/her personal information to a designated person.

Personal Representative Authorization Form – Disclosing Personal Information (MassHealth members)
This form is to be used by MassHealth members to authorize FCHP to disclose his/her personal information to a designated person.    

Personal Representative Authorization Form – Filing an Appeal (Fallon Senior Plan and NaviCare HMO SNP members)
This form is to be used by Senior Plan and NaviCare members to authorize someone to file an appeal on the member’s behalf.   Note:  This form automatically expires after a year.

Personal Representative Authorization Form – Filing an Appeal (MassHealth members)
This form is to be used by MassHealth members to authorize someone to file an appeal on the member’s behalf.

Personal Representative Authorization Form – Filing an Appeal 
This form is to be used by commercial (e.g. Select Care, Direct Care, PPO) members to authorize someone to file an appeal on the member’s behalf.

Request for an Accounting of Disclosures of Personal Information form 
Request a listing of who FCHP has shared your information with (after April 14, 2003) for reasons other than treatment, payment or health care operations.

Restriction form
Request a limit on how we use or share your personal information.