Participant Authorization Form 10

CARPENTERS HEALTH AND WELFARE TRUST FUND FOR CALIFORNIA

P.O. Box 2280 Oakland, CA 94621-0180

Tel. (510) 633-0333 η (888) 547-2054 η Fax (510) 633-0215 PARTICIPANT AUTHORIZATION FORM – Except to provide Treatment, Payment, or Health Care Operations, or as required by law, the Carpenters Health and Welfare Trust Fund will not disclose one person’s Protected Health Information (as that term is defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)) to anyone else, other than to an Authorized Representative, without this Authorization Form. [A separate authorization must be used if the authorization is for psychotherapy notes.]

Participant Granting Authorization: _________________________ Birth Date:_________________ Month Day Year

Participant’s Social Security Number/Participant ID Number:________________________________

Address: ____________________________________ Home Telephone:___________________

______________________________________ Work Telephone: ___________________ E-Mail Address: ___________________

By signing this authorization form I authorize the person(s) and/or organization(s) as listed in Section 2 and/or Section 3, to use and/or disclose my health information in the manner described below. Those authorized to use and/or disclose my information may not condition treatment, payment, or enrollment in a health plan or eligibility for health care benefits on my decision to sign this authorization, except as follows:

The Carpenters Health and Welfare Fund for California may condition the payment of a claim on

the authorization if the purpose of this authorization is to allow the Fund to obtain information it needs to make a claim payment determination and psychotherapy notes are not requested.

I understand that I am under no obligation to sign this form. I have signed this form voluntarily to document my instructions regarding the use and/or disclosure of the health information described in Section 1 of this form.

Participant Authorization Form 11

Section 1. Description of Health Information I Authorize to be Used or Disclosed. The following is a specific description of the health information I authorize to be used and/or disclosed: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Section 2. Persons/Organizations Authorized to Use and/or Disclose My Health Information. I authorize the following person(s) and/or organization(s) (or classes of persons and/or organization) to use and/or disclose the health information described in Section 1.

Carpenter Fund’s Office Staff Fund’s Claims Paying Staff Union Representative Others as Specified _______________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Section 3. Persons/Organizations Authorized to Receive and/or Use my Health Information. I authorize the following person(s) and/or organization(s) (or classes of persons and/or organizations) to receive my health information from the person(s) and/or organization(s) described in Section 2, and to use or disclose such information for the purposes listed in Section 4 of this form. I understand that if the person(s) and/or organization(s) listed in Section 4 are not health care providers, health plans or health care clearinghouses subject to federal privacy standards, the health information disclosed pursuant to this authorization may no longer be protected by the federal privacy standards and such person(s) and/or organization(s) may redisclose my health information without obtaining my authorization. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Section 4. Description of Each Purpose for the Requested Use and/or Disclosure. I authorize my health information to be used and/or disclosed for the following specific purpose: __________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________

Participant Authorization Form 12

Section 5.

Your Rights with Respect to this Authorization

5.01 Right to Revoke. I understand that I have the right to revoke this authorization at anytime. I also understand that my revocation of this authorization must be in writing. To obtain a copy of an authorization revocation form I may contact the Fund’s Privacy Officer at 265 Hegenberger Road, Suite 100, Oakland, California, 94621, (510) 633-0333. I am aware that my revocation will not be effective as to uses and/or disclosures of my health information that the person(s) and/or organization(s) identified in Section 2 and Section 3 of this form have already made in reliance upon this authorization.

5.02 Right to Inspect or Copy the Health Information to be Used or Disclosed. I

understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed in accordance with this form. I may arrange to inspect my health information or obtain copies of my health information by contacting the Fund’s Privacy Officer at 265 Hegenberger Road, Suite 100, Oakland, California, 94621, (510) 633-0333.

Section 6. Expiration of Authorization. This authorization will expire (choose and complete one option):

Date ________________________________________ Month Day Year

Upon the occurrence of the following event(s) related to my health care or to the

purpose(s) for which I have authorized the use and/or disclosure of my health information described in Section 3 of this form:

__________________________________________________________________________________________________________________________________________________________________________________________________________________

Section 7. By signing this form, I am confirming that it accurately reflects my instructions. I, _________________________________ have reviewed and understand the contents of this form.

Print Your Name _________________________________________ _____________________________________ Participant’s Signature Date If signed by a Personal Representative, complete the following:

Participant Authorization Form 13

Name of Personal Representative: ______________________________________________________________ Print Your Name Relationship to participant or nature of authority (e.g. health care power of attorney, guardian, or other statutory authorization):________________________________________________________________________ Personal Representative’s Address:____________________________________________ ____________________________________________ ____________________________________________ Personal Representative’s Home Phone Number:__________________________________ Work Phone Number:__________________________________ E-Mail Address:_______________________________________ ____________________________________ _________________________________________ Personal Representative’s Signature Date