Healthequity Hipaa Release Form


HIPAA Release Form
Mail or fax completed forms to:
Address: HealthEquity, A n: Member Services
15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020
Authoriza on to Release Protected Health Informa on
Dependents must complete this form to authorize the release of protected health informa on to the account holder.
Primary Account Holder Informa on
Last Name
First Name
Street Address
E-Mail Address (required)
Day me Phone
SSN or HealthEquity ID Number (6 or 7 digits)
HIPAA Release (to be completed by dependent)
My protected health information is individually identifiable health information, including demographic information
collected from me or created or received by a health care provider, a health plan, my employer, or a health care
clearinghouse, and relates to: (i) my past, present, or future physical or mental health condition; (ii) the provision of
the health care to me; or (iii) the past, present or future payment for the provision of health care to me.
In accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA), I, the
undersigned, grant permission to HealthEquity, Inc. to disclose protected health information (as defined in HIPAA) to
the following person or persons:
Purpose of authorization:
At my request
Family member assisting with health care
Any limitations that I impose on HealthEquity with respect to this authorization are declared below:
This release will remain in effect until the closure of the health savings account (HSA), flexible spending account
(FSA), or health reimbursement arrangement (HRA). In addition, I may revoke this Release at any time by notifying
HealthEquity of the revocation in writing and faxed to 801.727.1005, Attn: Member Services.
If at any time you need to alter this release form, please contact HealthEquity at 866.346.5800.
Authoriza on of HIPAA Release (to be completed by dependent)
I understand that by gran ng this Release, the person who obtains this informa on may disclose it to other individuals
with or without my consent and in so doing, the informa on would no longer be protected under HIPAA. I understand
that my authorizing the use and disclosure of my informa on is not a condi on of enrollment in this health plan,
eligibility for benefi ts or payment of claims.
Dependent’s Date of Birth
Date Authoriza on Eff ec ve Un l (If no date is provided, authoriza on is valid
un l the preset me frame based on your state.)
Dependent’s Name (please print)
Dependent’s Signature
Note: If the person signing above is a personal representa ve of the named individual, a ach copy of document gran ng authority to the
personal representa ve.


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Parent category: Medical