HIPPA AUTHORIZATION FORM

The purpose and design of the HIPAA Authorization Form is to protect the health information of our insured members. The form provided is to allow you, the member, to authorize the release of your Protected Health Information to the individuals, representatives, and organizations you may wish to have access to your information.

ACI will not release your information to others who have requested it, verbally or in writing, without your signature on a completed HIPAA Authorization Form.

HIPPA Authorization Form

HIPPA Formulario de Autorización