Care1st Health Plan Arizona

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

HIPAA and You

HIPAA stands for the Health Insurance Portability and Accountability Act of 1996.  According to Medicare, “the Standard for Privacy of Individually Identifiable Health Information (also called the 'Privacy Rule') of HIPPA makes sure your health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being” (

Care1st Health Plan Arizona (“Care1st”). has taken the necessary safeguards to protect your PHI and has developed policies and provided training on the issue to assist our staff.  Care1st also offers HIPAA-related resources to doctors and other providers who are involved in your health care. We will keep you informed of our continued HIPAA efforts.


HIPAA Authorization to Release Record of Protected Health Information (PHI) [Download Form]

  • This form allows you to
    • Request health information records of yours that we have on file (claims information, appeals information, prior authorization information and pharmacy history information).
    • Give permission for someone to obtain a copy of your records that we have on file
  • This form also allows your legal representative (such as a guardian or durable health care power of attorney) to request your health information records that we have on file (we require proof that the person making the request is really your authorized representative, if we don’t already have that information on file).

Authorization to Share Personal Health Information [Download Form]

  • This form allows you or your legal representative (such as a guardian or durable health care power of attorney) to
    • Allow Care1st to discuss/give out your personal health information to a person you select
    • This is for verbal (or over the phone) information Care1st gives to someone of your choosing
  • Note that you do not have to submit this request in writing. Care1st may share your personal health information to a person of your choosing if you contact Care1st and give your permission over the phone.

Appointment of Representative Form (CMS-1696)

For Care1st members, an appointed representative is a person who can act on your behalf to request:

  1. An appeal; and/ or
  2. Grievance/ Complaint;

This person can be a relative, friend, advocate, or anyone else you trust to act on your behalf. If you want to appoint someone to act for you regarding an appeal and/or grievance/complaint, then both you and the person you assign has to sign and date this statement that gives your assigned person legal permission to act as your appointed representative. Please note that your doctor or other prescriber is not required to submit this form or other equivalent notice.

You can use this form, OR you can make your own statement (an equivalent written notice) as long as it contains all the required information.

  • Includes the name, address, and telephone number of member;
  • Includes the member’s AHCCCS ID Number;
  • Includes the name, address, and telephone number of the individual being appointed;
  • Contains a statement that the member is authorizing the representative to act on his or her behalf for the claim(s) at issue, grievance or appeal; and a statement authorizing disclosure of individually identifying information to the representative;
  • Is signed and dated by the member making the appointment; and
  • Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment

A completed AOR is

  • Good for 1 year from the signature date;
  • Valid for the duration of the appeal or grievance/ complaint.

Request for an Accounting Disclosure [Download Form]

  • You may request a list of our disclosures of your PHI. The list we give you will include disclosures made in the last six years, unless you request a shorter time or if less than six years have passed since April 14, 2003. You are entitled to one disclosure accounting in any 12-month period at no charge. If you request any additional accounting less than 12 months later, we may charge a fee.
  • An accounting does not include certain disclosures – for example: disclosures to carry out treatment, payment, and health care operations; disclosures provided to you or your family directly, or information that was shared because you gave us your permission in writing.

Privacy Practices Complaint [Download Form]

If you want to lodge a complaint about our privacy practices, please let us know. You are not required to fill out this form in order to file a privacy practices complaint. You may file by calling our Member Services Department. Click Here to locate our Privacy Practices, which offers additional information on ways to file a privacy complaint.

Request for an Amendment of PHI [Download Form]

  • Please fill out this form if you believe there is a mistake in your PHI or that important information is missing and you are requesting that we correct or add to the record.

Request for Confidential Communications [Download Form]

  • You may request us to send your protected health information (PHI) to you at an alternative location (for example, your work address) or by a different means (for example, via fax instead of regular mail). To do so, you must complete this form and return it to Care1st at the address provided in the document. If the cost of meeting your request involves more than a reasonable amount, we are permitted to charge you our costs that exceed that amount.

Request to Limit Uses and Disclosure of PHI [Download Form]

  • You can tell Care1st what information you do not want to share and who you don't want us to share your information with. We will review and consider your request. Care1st is not required to agree with your request. If we don't agree with your request we will let you know.


Click Here to read more information on doing your part in preventing health care identity theft, including fraud, waste and abuse!

HIPAA Resources

U.S. Department of Health & Human Services’ Office of Civil Rights (OCR)

  • Answers to Frequently Asked Questions, additional HIPAA information, including HIPAA-related laws, regulations, and enforcement - Click Here or call OCR's toll-free number at: 1-866-627-7748


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