Transcription of HIPAA REQUEST FORM - whymetlife.com
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HIPAA REQUEST FORM - whymetlife.com
HIPAA REQUEST form If you wish to include in your booklet certificate the HIPAA privacy language shown on the specimen "Sample Dental or Vision Booklet Certificate/SPD Language" provided to you by MetLife, please answer the following question(s), sign, and return this form to MetLife at the following address: MetLife 4150 N. Mulberry Drive/Suite 300 Kansas City, MO 64116 Please provide the following information: there employees of the Plan Sponsor that may access PHI (Protected HealthInformation) provided by the Plan? If there are, please provide their title(s) orother identifiers below. Please do not provide their names, only title or _____ _____ _____ the term "Privacy Officer" be included in Section III.
HIPAA REQUEST FORM If you wish to include in your booklet certificate the HIPAA privacy language shown on the specimen "Sample Dental or Vision Booklet Certificate/SPD Language" provided to
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