Tricare Form - Anchor Psychological And Counseling Services (Page 2 of 2) in pdf

Tricare Form - Anchor Psychological And Counseling Services Page 2

Privacy Act Statement

This statement serves to inform you of the purpose for collecting personal information required by the PGBA,

LLC (PGBA) and how it will be used.

10 U.S.C. Chapter 55, Medical and Dental Care: 38 U.S.C. Chapter 17, Hospital,

AUTHORITY:

Nursing Home, Domiciliary, and Medical Care; 45 CFR Parts 160 and 164, Health

Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules;

32 CFR 199.17, TRICARE Program; and E.O. 9397 (SSN), as amended.

PURPOSE:

To provide eligibility, enrollment, deductibles, catastrophic caps, claims processing,

and customer service to individuals eligible for TRICARE benefits.

ROUTINE USES:

In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the

Privacy Act of 1974, as amended, these records may specifically be disclosed

outside the Department of Defense as a routine use pursuant to 5 U.S.C. 552a(b)(3)

as follows: to the Department of Veterans Affairs, the Department of Health and

Human Services, the Department of Homeland Security, and to other federal, state,

local, or foreign government agencies, and to private business entities, including

entities under contract with the Department of Defense and individual providers of

care, on matters relating to eligibility, claims pricing and payment, fraud, program

abuse, utilization review, quality assurance, peer review, program integrity, third-

party liability, coordination of benefits, and civil or criminal litigation.

DISCLOSURE:

Voluntary. If you choose not to provide your information, no penalty may be imposed,

but absence of the requested information may result in administrative delays.

Tricare Form - Anchor Psychological And Counseling Services Page 2