Healthcare HIPP Notice

HEALTHCARE HIPP NOTICE

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

Primary Insurance Provider:

EMPLOYER/EMPLOYMENT INFORMATION

HIPP NOTICE AND AUTHORIZATION

Purpose: The Health Insurance Premium Payment (HIPP) Notice explains the process of determining eligibility for a premium payment program intended to obtain or maintain third‑party health coverage. This Notice requests authorization to examine, obtain and disclose information necessary to evaluate eligibility for premium assistance and to coordinate benefits.

I certify the following (select all that apply):

I currently have employer‑sponsored health coverage through the employer identified above.

My employer offers health coverage and I may be eligible for employer contributions toward premiums.

I do not have employer‑sponsored coverage at this time.

Monthly premium amount for employer plan (if known):

Authorization to Release and Obtain Information: I authorize any current or past health care provider, health plan, insurer, employer, payroll administrator, benefits administrator, and other third parties to disclose and release to the Health Insurance Premium Payment Unit, its agents, and its contractors all information relevant to determining eligibility for premium assistance. This includes, but is not limited to, enrollment records, premium amounts, employer contribution information, payroll and benefit records, and claims information for myself and any dependent for whom I am legally authorized to act.

Purpose of Disclosure: The information obtained will be used to determine eligibility for premium assistance, to coordinate benefits, and to arrange payment of premiums to a third‑party insurer on my behalf where authorized. A copy of this authorization is as valid as the original.

Right to Revoke and Expiration: I understand that I may revoke this authorization at any time by submitting a written revocation to the HIPP Unit. Revocation will not affect disclosures made prior to receipt of the revocation. This authorization expires on:

Assignment of Rights and Payment: If premium payments are approved, I assign to the entity making payments the right to recover premium payments from any third party responsible for benefits. I understand that any premium payments made on my behalf may be subject to audit and recovery if paid in error or based on incorrect or fraudulent information.

Certification and Penalties: I certify under penalty of perjury that the information I have provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false information or withholding material facts may subject me to civil or criminal penalties and may result in denial, cancellation, or recovery of premium payments.

HIPAA AND PRIVACY ACKNOWLEDGMENT

Acknowledgment: By signing below I acknowledge that I have been advised of and understand the Notice of Privacy Practices regarding the use and disclosure of my protected health information for the purposes described in this Notice and that a copy of the Notice has been made available to me upon request.

I acknowledge receipt of the Notice of Privacy Practices.

AUTHORIZATION CERTIFICATION

I certify that I have the legal authority to give this authorization for myself and for any dependents named on this form. I understand that copies of records obtained under this authorization may be retained and disclosed as necessary to determine eligibility and coordinate benefits. I understand that premiums paid under the HIPP program do not alter my or my dependents' rights under employer plan documents.

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