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Member Privacy Forms

The following are forms you, as a Health Partners Plans (HPP) member, or your personal representative, may use to exercise your privacy rights relating to the health information Health Partners Plans creates, obtains, and/or maintains about you. All forms are in PDF format: 

Request for Access to Protected Health Information
This form allows you or your personal representative to request access to review or obtain a copy of your protected health information (PHI) maintained by HPP.

Authorization for the Use or Disclosure of Protected Health Information
This form allows you or your personal representative to authorize HPP to discuss or release your protected health information (PHI).    

Request for Amendment of Protected Health Information
This form allows you to request a change or correct your protected health information (PHI) that Health Partners Plans maintains. 

Request for Restriction on the Use or Disclosure of Protected Health Information
This form is used to limit or restrict who your protected health information (PHI) is disclosed to or how it is used.

Request for Alternative Communications
This form allows you to request that HPP send your protected health information (PHI) to you at an alternative address.

Revocation/Cancellation of Authorization
This form allows you to change/cancel your existing authorization or requests.