Privacy Statement & HIPAA Forms

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Important Notice: Pennsylvania Life and Health Insurance Company Guarantee (PDF)

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HIPAA Privacy Forms

*All documents are in PDF format

UPMC Health Plan (Commercial)

• Notice of Privacy Practices
• Personal Representative Designation Form
• Member Authorization to Use/Disclose PHI
• Alternate Address Request Form
• Formulario de nombramiento de representante personal

UPMC for Life (Medicare)

• Notice of Privacy Practices HMO/PPO Members
• Personal Representative Designation Form
• Member Authorization to Use/Disclose PHI

UPMC for You (Medical Assistance)

• Notice of Privacy Practices
• Notificación de prácticas de privacidad
• Personal Representative Designation Form
• Formulario de Designación de Representante Personal
• Member Authorization to Use/Disclose PHI
• Personal Representative Designation Form – 繁體中文/Mandarin (Chinese)
• Personal Representative Designation Form – 한국어/Korean
• Personal Representative Designation Form – ខ្ខ្មែរ/Mon-Khmer (Cambodian)
• Personal Representative Designation Form – Tiếng Việt/Vietnamese
• Personal Representative Designation Form – Русский/Russian
• Personal Representative Designation Form – नेपाली/Nepali
• Personal Representative Designation Form – 
  نموذج تعيين الممثل الشخصي  

UPMC for Kids (Children's Health Insurance Program)

• Notice of Privacy Practices
• Personal Representative Designation Form
• Formulario de nombramiento de representante personal
• Member Authorization to Use/Disclose PHI
• Autorización del miembro para usar o divulgar información de salud protegida
• Notificación de prácticas de privacidad

UPMC Medicare Special Needs Plans

• Notice of Privacy Practices
• Personal Representative Designation Form
• Member Authorization to Use/Disclose PHI

UPMC Community HealthChoices

• Notice of Privacy Practices
• Personal Representative Designation Form
• Formulario de Designación de Representante Personal
• Personal Representative Designation Form - 繁體中文/Mandarin (Chinese)
• Personal Representative Designation Form - 한국어/Korean
• Personal Representative Designation Form - ខ្ខ្មែរ/Mon-Khmer (Cambodian)
• Personal Representative Designation Form - Tiếng Việt/Vietnamese
• Personal Representative Designation Form - Русский/Russian
• Personal Representative Designation Form - नेपाली/Nepali
• 2024 Personal Representative Designation Form – 
  نموذج تعيين الممثل الشخصي 
• Member Authorization to Use/Disclose PHI