GB-05 PHI Authorization Form

This form is completed by the member giving authorization to an authorized individual for the disclosure of health care information on member or dependents verbally or in writing.

GB-12 HIPAA Authorization for Dependent Child Medical Information Request Form

This form is intended to be used by OGB health plan participants to provide valid authorization for the release of their dependent’s medical records.

GB-14 HIPAA Privacy Complaint

This form is intended to be used by OGB health plan participants to file a complaint concerning possible violations of the federal HIPAA privacy law, Louisiana state law that preempts HIPAA, and/or the OGB privacy policies and procedures.

GB-15 HIPAA Request for Access to Protected Health Information

This form is intended to be used by OGB health plan participants to review or obtain copies of his/her protected health information (PHI). OGB may charge a fee for the cost of producing, copying, and mailing the PHI.

GB-16 HIPAA Request for Accounting of Disclosure of Protected Health Information

This form is intended to be used by OGB health plan participants to request an accounting of OGB disclosures of their protected health information (PHI).

GB-17 HIPAA Request for Amendment of Protected Health Information

This form is intended to be used by OGB health plan participants to request that OGB amend any errors in their protected health information (PHI) maintained by OGB.

GB-18 HIPAA Request for Restriction of Protected Health Information

This form is intended to be used by OGB health plan participants to request that OGB restrict or limit how OGB uses or discloses their protected health information (PHI) for treatment, payment, or health care operations.

GB-19 HIPAA Revocation of Authorization for Use or Disclosure of Health Information

This form is intended to be used by OGB health plan participants to revoke any authorization for use or disclosure of their protected health information (PHI), except to the extent that OGB has taken action in reliance on the authorization or to the extent OGB is permitted by law to contest a claim or coverage under the OGB health plan.

HIPAA Notice of Privacy Practices

This notice describes the uses and disclosures of protected health information (PHI) that may be made by OGB; OGB health plan participant rights; and OGB’s legal duties with respect to PHI.