How do I give Tufts Health Plan permission to discuss my benefits?

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects your health information. Tufts Health Plan cannot disclose your protected health information (PHI) without your consent. If you want us to be able to discuss your health information with another person, such as a spouse or family member, we have several authorization forms on our website.

I need Tufts Health Plan to share my information with another person or entity. What form do I use?

Use the Authorization to Disclose Protected Health Information Form. This form allows you to name the recipient, as well as what type(s) of information you’d like us to disclose.

Your authorization will remain in effect for 2 years, unless you specify an alternative end date.

I need to designate another person to act on my behalf. What form to do I use?

Use the Designated Representative Form. This form may be used to designate a representative to act on your behalf and authorize Tufts Health Plan to disclose your PHI to the representative. Your authorization will remain in effect for 2 years, unless you specify an alternative end date.

I need to give another person legal permission to file a claim, appeal, grievance, or request with the Centers for Medicare & Medicare Services. What form do I use?

Use the Centers for Medicare & Medicaid Services Appointment of Representative Form. Your appointment is valid for 1 year from the date you and your representative sign.

Can I revoke my authorization(s)?

Yes. For the Authorization to Disclose Protected Health Information and Designated Representative authorizations, you can revoke your authorization in writing using the Termination of Authorization or Restriction Form.