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HIPAA Forms

For General Health Forms, please see the Health Forms page

or Pension Forms, please see the Pension Forms page

You'll need the free Acrobat Reader to view these forms.

Appointment of Personal Representative Form

Use this form to authorize a personal representive to act for you in receiving any information provided to you as a participant/beneficiary of the Plan.


Request That PHI Be Transmitted Confidentially by Alternate Means

Use this form to authorize different address or manner or place where an individual will receive PHI (Protected Health Information).


HIPAA Complaint Form

Use this form to submit a complaint, such as perceiving an employee violating the privacy policies and procedures.


Request for Access to PHI Form

Use this form to request to inspect and copy specified PHI (Protected Health Information).


Request for Restrictions on Use & Disclosure

Use this form to request that use and access to PHI (Protected Health Information) be restricted in a specified manner.


Request for Accounting of Disclosure of PHI

Use this form to request an accounting of the disclosures of PHI (Protected Health Information).

Please mail the completed forms to:

Equity-League Health Trust Fund
165 W 46 St, Ste 402
New York, NY 10036.

©2001, 2002 Equity League Pension and Health Funds This site does not change or otherwise interpret the official Plan documents. To the extent that any of the information contained in this website is inconsistent with the official Plan documents (which, of course, includes the Trustees' rights to amend or modify the Plans at any time), the plan documents will govern in all cases. No official (other than the Trustees) has any authority to interpret the Plans, or other official Plan documents, or to make any promises to you about them. Terms of Use | Privacy Policy