General Forms - University of Maryland Health Advantage

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General Forms

Electronic Funds Transfer (EFT) Form	Use this form to allow your plan to withdraw your monthly plan premium payment from your checking account on the 15th of each month. Please return the EFT form to the following address: University of Maryland Health Advantage Attention: Premium Billing 1966 Greenspring Drive, Suite 100 Timonium, MD 21093
Social Security & Railroad Retirement Board Premium Deduction Authorization	Use this form to sign-up to have your monthly plan premium automatically deducted from your Social Security or Railroad Retirement Board check. Please return the Social Security & Railroad Retirement Board Premium Deduction Authorization Form to the following address: University of Maryland Health Advantage Attention: Enrollment 1966 Greenspring Drive, Suite 100 Timonium, MD 21093
Notice of Privacy Practices	This notice that tells you how we may use and share your health information and how you can exercise your health privacy rights. You should have received this notice in your Evidence of Coverage. You can either download this copy or call Member Services at the telephone number on the back of your membership ID card to obtain a copy at any time. We cannot use or disclose information in a way that is not consistent with our notice.
HIPAA Consent and Authorization Form	This consent form allows University of Maryland Health Advantage to use and disclose information about you protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) with the individual(s) you list on the form for the purpose(s) of administering your healthcare benefit plan and providing you with Case Management and other services as deemed appropriate. Furthermore it allows you to designate specific individuals to act as your authorized representative for specific purposes you designate on the form until such time as you revoke your authorization.
Waiver of Liability Statement (For Non-Contracted Providers )	This form is for non-contracted providers to use when filing an appeal with University of Maryland Health Advantage. This form must accompany a non-contracted provider's request for an appeal and must be received by the Plan within 60 calendar days of receipt of the Plan's initial decision to deny a service and/or payment of services previously rendered. Non-Contracted Provider appeals should be mailed to: University of Maryland Health Advantage Attention: Appeals & Grievance Department 1966 Greenspring Drive, Suite 100 Timonium, MD 21093
Request for Access to Protected Health Information Form	Use this form when you want University of Maryland Health Advantage, Inc. to provide you with access to your protected health information (PHI) that is maintained by University of Maryland Health Advantage, Inc. Simply click on the link to the left to open the form, complete it, print it out and mail it to University of Maryland at the address designated on the form.
Request for Accounting of Protected Health Information Disclosures	Use this form when you want University of Maryland Health Advantage to provide you with an accounting of how it has used and disclosed your protected health information (PHI). Simply click on the link to the left to open the form, complete it, print it out and mail it to University of Maryland at the address designated on the form.
Request to Amend or Change Your Protected Health Information	Use this form when you want University of Maryland Health Advantage to change or amend the protected health information (PHI) it maintains on you. Simply click on the link to the left to open the form, complete it, print it out, and mail it to University of Maryland at the address designated on the form.
Request to Restrict the Use and/or Disclosure of Your Protected Health Information	Use this form when you want University of Maryland Health Advantage, Inc. to restrict the use and/or disclosure of your protected health information. Simply click on the link to the left to open the form, complete it, print it out and mail it to University of Maryland at the address designated on the form.