Protected Health Insurance Form (PH-3880)
Request in writing.
Must state time period requested
May account for a 6 year period
1. a person's health, health care, or payment of health care (the term "health" includes mental health and behavioral health issues)
2. information that identifies a person
3. services created or received by a covered health care plan or provider.
Name, Address, Zip, Sub-Division, Phone Number, Driver's License Number, Race, Religion, Marital Status, SSN, Income, etc.
Paper
Electronic
Oral
1. Required by law
2. Permitted disclosures for public health activities (such as reporting diseases, collecting vital statistics, etc.)
3. Disclosure about victims of abuse, neglect or domestic violence
4. Health oversight activities
5. Judicial or administrative proceedings
6. Law enforcement purposes
7. Research purposes
8. To avert a serious threat to health or safety
"Minimum necessary"
1. Right to receive a “Notice of Privacy Practices”
2. Right to authorize any use or disclosure of protected health information
3. Right to restrict use or disclosure of protected health information
4. Right to an accounting of disclosure of protected health information
5. Right to inspect, copy and request amendments to protected health information