Get Wisconsin Seniorcare Hipaa Privacy Communication Request, F-13164. Hipaa For Seniorcare - Dhs

This guide provides a comprehensive overview of the Wisconsin SeniorCare HIPAA Privacy Communication Request, form F-13164. By following these instructions, users will be able to understand and complete the form effectively, ensuring their privacy communication preferences are appropriately communicated.

Follow the steps to complete the Wisconsin SeniorCare HIPAA Privacy Communication Request form online.

1. Click the ‘Get Form’ button to obtain the Wisconsin SeniorCare HIPAA Privacy Communication Request, form F-13164, and open it in your chosen document editor.
2. In Section I, member information, enter your full name (last, first, middle initial) in the provided fields. Next, provide your SeniorCare Identification Number, followed by your full address including street, city, state, and ZIP code. Finally, input your telephone number.
3. In Section II, Alternative Communication Request, read the instructions carefully. Describe the specific protected health information you wish to have communicated through alternative means. Then, indicate your preferred alternative methods of communication and provide any full details that are necessary.
4. If applicable, specify an alternative location where you would like to receive communications about your protected health information. Include all relevant information related to this alternative location.
5. In Section III, Signatures, sign and date the form in the space provided under the member's signature section. If a personal representative is submitting the request on your behalf, include their name, relationship to you, and their signature and date.
6. After completing all sections, review the form for accuracy. You can then proceed to save your changes, download, print, or share the completed form as needed.

Ensure your communication preferences are respected by completing the Wisconsin SeniorCare HIPAA Privacy Communication Request online today.