Kaiser HIPAA Authorizations
PLEASE READ: If you will be enrolled in the Kaiser HMO plan for the 2023 Plan Year, the following information APPLIES TO YOU. As a Member, and/or enrolled Spouse/Domestic Partner please accept your Kaiser HIPAA Acknowledgement form, as seen below. If you have an enrolled dependent child that is an adult (18+) please have them submit their own Acknowledgement form. Read on for more information.
Please read and accept the disclosure below. Please print and fill out the Kaiser HIPAA Authorization form and submit to the Trust Fund Office through your ufcwtrust.com Participant Account. See below for further directions.
You are an enrolled participant and must read and accept the Kaiser HIPAA Agreement.
Members, covered Spouse/Domestic Partners, and Children over age 18 MUST each complete and SIGN their own individual Kaiser HIPAA Authorization form. See below to print the paper form.
Kaiser HIPAA Disclosure and Acknowledgments
UFCW & Employers Trust, LLC
Health Reimbursement Account (HRA)
Disclosure and Authorization for Kaiser HMO Participants
As a participant in the Fund who has enrolled in the Wellness Program (HCP), you have access to a Health Reimbursement Account (“HRA”). You may use funds in your HRA to pay or be reimbursed for your out-of-pocket expenses. Details concerning your HRA benefit are described in the program materials you will receive or have received from the Fund.
In order for the Fund to determine the amounts to be paid or reimbursed to you from your HRA for out of pocket expenses incurred in your Kaiser HMO plan, and for other reporting and administrative purposes, Kaiser will need to provide the Trust Fund Office your demographic information (name, social security number, date of birth, and/or other identifying and contact information) and your claims information (collectively “protected health information” or “PHI”).
Specifically, your Kaiser HMO plan (the Kaiser Foundation Health Plan, Inc., Northern California Region) will share information about you with the Trust Fund Office for purposes of administering the HRA feature, but only if you authorize your Kaiser HMO plan to share such information.
Please print and fill out the following form:
DURATION: This authorization shall become effective immediately and shall remain in effect for a year from the date of your signature, except in California (where this authorization is valid until 12/31/2023.)
REVOCATION: I understand that I may revoke this authorization in writing at any time by contacting the Trust Fund Office and requesting a revocation form, or submitting my request through the ufcwtrust.com website behind the login. The written revocation will be effective upon receipt, except to the extent that the disclosing party or others have acted in reliance upon this authorization.
HOW TO SUBMIT YOUR FORM
*NOTE: The online upload feature is available on Member accounts only. Members can submit all signed dependent forms through their account.
1. Log in to your UFCWTrust.com Participant Account
2. Go to the Correspondence tab, and click the “Upload” button to submit your signed and scanned forms.
3. Click the “Upload” button to submit your signed and scanned form. Be sure to select “Kaiser HIPAA Authorization” from the drop down menu upon uploading your form.
You can also submit your form through postal mail or drop it off in-person to one of our offices:
- Mail: PO Box 4100, Concord, CA 94524-4100
- Fax: (925) 746-7549
- Concord Drop Off: 1000 Burnett Ave, Suite 110, Concord, CA 94520
- Roseville Drop Off: 2200 Professional Drive, Suite 200, Roseville, CA 95661