The staff of the Student Health Insurance office strives to provide excellent service to our insured, their families, and the health care providers who serve them. Providing accurate and confidential records helps us to accomplish this goal. We know that from time to time it is necessary for an insured to ask assistance from others in seeking information about their coverage and the processing of their medical claims. However, due to HIPAA regulations, our staff cannot disclose an insured's personal information to anyone other than the insured, or the provider of the services, without the written authorization from the insured.

There are two authorization forms. The Personal Representative Appointment form allows this office to disclose all of the same information that is available to the insured. This form automatically expires at the end of each plan policy year. The second form is the PRI-SI-FO Authorization form. This form allows the insured to determine exactly what information can be disclosed, such as only information concerning, heart condition. It also allows the insured to state how long the information can be disclosed by choosing an exact expiration date or having the authorization expire after the close of an event, for example, after graduation. The insured has a right to revoke the authorization at any time by giving written notice.

 

Personal Representative Appointment Form

This form allows you to give authorization for another person(s) to have the same rights to your health insurance information that you are given. This means the person you authorize has access to ALL information concerning your Student Health Insurance records.

This form is self-explanatory. Please make sure the form is signed by you on the lower right. This form will automatically expire on the last day of the plan year in which the form is signed.

A notice of verification that the form has been received will be sent to your UIUC e-mail address, unless the form is submitted in person to the Student Health Insurance office.

Please go to Important Forms to download a copy of the Personal Representative Appointment Form.

PRI-SI-FO-09 form

This form allows you to give very specific authorization concerning your records. Please read the form carefully before you begin.

Section A: If you wish to give authorization for psychotherapy notes and medical information, you will need to complete two of these forms; one for psychotherapy notes and one for medical information.

Section B: Insured information

Section C: You must be very specific as to the information you want released. An example of this would be information concerning a specific injury or illness, such as all information concerning injury to my right leg or all information concerning my asthma. You must also state the name(s) of those you wish to give authorization. If you wish both parents to have access to your information, you must state both of their names.

Section D: This requires that you provide a specific date or event in which the authorization ends. If the specific event is the date of graduation, you must state the date you will graduate.

The next section includes your signature for authorization. If a personal representative signs this form, documentation such as power of attorney or court order must be attached.

A notice of verification that the form has been received will be sent to your UIUC e-mail address, unless the form is submitted in person to the Student Health Insurance office.

All incomplete forms will be voided.

Please go to Important Forms to download a copy of the PRI-SI-FO-09 Individual Authorization Form.

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The MegaLife Health Insurance Privacy Statement is available in two formats:

• A four page, letter size PDF
• A two page, pamphlet size PDF

Please go to Important Forms to download a copy of the MegaLife Privacy Statement.