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 Required Notices

PHI Notices

  • You may give written Authorization to disclose your protected health information (PHI) to anyone that you designate and for any purpose.
  • If you wish to authorize a person to receive your PHI, please complete the information below.
  • Unless this Authorization form is filled out, PHI will NOT be disclosed to anyone other than the patient.
  • An Authorization MUST be filled out for each person you wish to receive your PHI.
  • In addition, an Authorization MUST be completed by each of your adult dependents.
  • Please note that in most cases an Authorization is NOT required for a parent or legal guardian to receive PHI on a minor child.

Yearly/New Hire Notices

Women's Health & Cancer Rights (WHCRA)

The document informs participants of their right to certain benefits following a mastectomy

COBRA Election Notice

Offers COBRA eligible members the opportunity to enroll

The Medicare Part D Disclosure Notice (Creditable Coverage)

Notifies eligible individual participants as to whether the plan's prescription drug coverage is creditable compared to Medicare Part D prescription drug coverage

Newborn and Mothers Health Protection Act

​Prohibits plan authorization requirement for mother’s stay in hospital after birth of 48 to 96 hours depending on birthing circumstances

The USERRA Private Notice

USERRA Protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System

The Employer CHIP Notice

This document describes the employee's and any dependent's right to enroll in the plan at a later date if they lose eligibility for Medicaid or CHIP or become eligible for state premium assistance

The Exchange Notice FLSA

This form is for anyone that is thinking about moving to a Marketplace Exchange insurance plan

HIPAA Notice of Special Enrollment Rights

​States circumstances in which you can enroll in the plan outside of the enrollment period

Salary Reduction Agreement

See full benefit summaries for details, exclusions, out of network information, & other coverage.  Covered expenses only. This web site is not a legal document.  This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only.  Benefits outlined on this web site are subject to change at any time.  Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility