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HIPAA - Personal Representative Form

A Personal Representative is a person entitled under applicable law to decide and act on behalf of a CCAI member with respect to the CCAI member’s health care. A Personal Representative is entitled to act on behalf of CCAI participant for purposes of exercising certain rights relating to:

CCAI member’s health information: Member’s name:

Member’s Address_________________________________________________________

Health Plan: ___________________________________ ID: _______________________

Representative’s name:

Best way to contact Representative:

Relationship to CCAI member (select one): ¨ Parent/guardian of the minor CCAI member - Attach a copy of the minor’s birth certificate or proof ofguardianship.

¨ Executor or administrator of the deceased CCAI member’s estate (please attach the necessary documentation thatestablishes your authority to make decisions on behalf of the CCAI member’s behalf):

o Letters Testamentary (Documents issued by the probate division of Circuit Court), oro Other legal documents evidencing executor or administrator status

¨ Other (please describe your relationship to CCAI member, and attach proof of your authority to make health caredecisions):

o Power of Attorney,o Court Order, oro Other legal documents evidencing guardianship status

I hereby certify that I am a person with legal authority to make health care decisions for CCAI member listed above. I have attached the required documentation to establish my status as CCAI member’s Personal Representative. I certify that the information on this Personal Representative Form is true, correct, and accurate to the best of my knowledge. I understand that CCAI may request information; now or in the future, as it deems necessary to confirm my Personal Representative status.

Signature Date

After you have completed this form please return it and all supporting documentation to the Privacy Official by mail or by facsimile at the following address:

Privacy Official Community Care Alliance of Illinois

P.O. Box 3358 Scranton, PA 18505 Fax: 1-855-231-8778

If you have questions about this form or about personal representative status, contact the Privacy Official at the address above.

For internal use only: ¨ Approved ¨ Denied

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Community Care Alliance of Illinois (CCAI) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CCAI does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: o Qualified interpreterso Information written in other languages

If you need these services, contact Member Services at 1-877-364-4566.If you believe that CCAI has failed to provide these services or discriminated in another way on

the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Member Services P.O. Box 3896Scranton, PA 18505

Phone: 1-877-364-4566 (TTY 711) Fax: 1-855-231-8778

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Member Services department is available to help you. You can also file a civil rights complaint with

the U.S. Department of Health and Human Services, Office for Civil Rights:

200 Independence Avenue SW., Room 509F HHH Building, Washington, DC 20201 Phone: 1-800-368-1019 TTY/TDD: 800-537-7697

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

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English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-364-4566 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-364-4566 (TTY: 711).

Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-364-4566 (TTY: 711).

Chinese -注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-877-364-4566 (TTY: 711).

Korean

-주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-364-4566 (TTY: 711). 번으로 전화해 주십시오.

Tagalog

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-364-4566 (TTY: 711).

Arabic

لك تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة 711 رقم) 4566-364-877-1 برقم اتصل .بالمجان

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-364-4566 (телетайп : 711).

Gujarati

!ચુના: જો તમે !જુરાતી બોલતા હો, તો િન:!#ુક ભાષા સહાય સેવાઓ તમારા માટ$ ઉપલ$ધ છે. ફોન કરો 1-877-364-4566 (TTY: 711).

Urdu

دستىاب مىں مفت خدمات كى مدد كى زبان كو آپ تو ہىں، بولتے اردو آپ اگر :خبردارTTY: 711) 4566-364-877-1 كرىں كال ۔ ہىں ).

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-364-4566 (TTY: 711).

Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-877-364-4566 (TTY: 711).

Hindi

!यान द": य"द आप !हंद% बोलते ह" तो आपके िलए म#ुत म" भाषा सहायता सेवाएं उपल$ध ह"। 1-855-275-2781 (���: 711) पर कॉल कर#।

French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-364-4566 (ATS : 711).

Greek

ΠΡΟΣΟΧΗ: Αν µιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1- 877-364-4566 (TTY: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-364-4566 (TTY: 711).