State of California – Health and Human Services Agency |
California Department of Public Health |
CONSENT AND WRITTEN AUTHORIZATION FOR USE AND
DISCLOSURE OF PERSONAL INFORMATION
OA-PCIP - INSURANCE ASSISTANCE SECTION
The California Department of Public Health (CDPH), Insurance Assistance Section (IAS) provides health insurance premium payment assistance to qualified California residents. If it is determined that you are eligible for premium payment assistance and also found eligible for coverage under the California Pre-Existing Condition Insurance Plan (PCIP) that is administered by the Managed Risk Medical Insurance Board (MRMIB) under contract with the U.S. Department of Health and Human Services (DHHS), CDPH will pay your PCIP insurance premium. In order to obtain the premium payment benefit, you will need to apply for IAS eligibility and, in a separate form, PCIP eligibility.
If you want to apply for this premium payment benefit, in order to establish your IAS eligibility, we need your written authorization (by signing this consent below) to allow CDPH to discuss and share your IAS application, medical verification of your condition (e.g., physician diagnosis), and personal information with the enrollment worker who provides application assistance and with MRMIB, third-party vendors with which MRMIB contracts, DHHS, and state and federal auditors.
In order to obtain health coverage under PCIP, we also need your authorization (by signing this consent below) to send your PCIP application to MRMIB, MRMIB’s third-party vendors and DHHS. Your PCIP application requires you to provide some personal information and may include your medical condition.
To verify eligibility for the IAS premium assistance project, your enrollment worker or CDPH may be required to obtain personal information from other agencies or health care providers. If you agree to take part in IAS, CDPH will collect personal information including your name, date of birth, address, Social Security Number, medical history, and financial eligibility for the project. The IAS information will be considered confidential, but may be released to health care providers, your enrollment worker, CDPH, MRMIB and its third-party vendors, DHHS, and state and federal auditors for the purposes of determining initial and continuing eligibility, processing payments, conducting audits and facilitate the operation and administration of both the premium assistance project and PCIP. Also, your information may be disclosed in connection with an administrative hearing or judicial proceeding between you and MRMIB, its third-party vendors or DHHS involving PCIP though efforts would be made to keep the disclosure to the minimum necessary. Confidentiality agreements are in place, which keep client information maintained by CDPH confidential except as described in this consent, or as otherwise allowed or required by law.
Personal information obtained or received by MRMIB, its third-party vendors or DHHS during the PCIP application process and during the operation of PCIP, such as claims provided by health care providers, will be maintained by MRMIB, its third-party vendors and DHHS and will be governed by the privacy laws and regulations to which they are subject in connection with PCIP instead of those to which CDPH is subject even though some of the personal information requested by CDPH is the same. For example, the privacy laws and regulations related to your medical condition are different for MRMIB, its third-party vendors and DHHS and CDPH. In addition, MRMIB, its third-party vendors and DHHS may be required to disclose your information in response to a subpoena or court order, while information maintained by CDPH is protected from disclosure in response to a subpoena. The PCIP Notice of Privacy explains the privacy laws and regulations applicable to PCIP and is found
at http://www.pcip.ca.gov/About/Privacy_PCIP.aspx.
Information that you provide for your IAS application may be made available to your local health department for statistical purposes. This information includes, but is not limited to, gender, ethnicity, zip code, diagnosis status, and date of birth. This information may also be used for professional writings under strict assurances that all identifying information including name and Social Security Number is deleted. Any professional or research reports that may be published will not use your name nor any personal identifying information.
