HIPAA Privacy Forms

Please submit completed forms to:

Corporate Privacy Office
Planned Administrators, Inc.
P.O. Box 6702
Columbia, SC 29260

Authorized Representative Form (English) Protected Health Information (PHI) is not released to anyone other than those specifically authorized by the insured using this form.

Formulario de Representante Autorizado (Español)  La Información Protegida de la Salud (PHI) no es liberada a nadie de otra manera que esos específicamente autorizado por el utilizar asegurado esta forma.

NOTICE OF PRIVACY PRACTICES

Form 3 - Authorization Form
Form 4 - Authorization for Marketing
Form 21 - Access Request 
Form 22 - Amendment Request
Form 23 - Disclosure Accounting Request
Form 25 - Restriction Request
Form 27 - Confidential Communications Request
Form 32 - Complaint Form

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