* = Required
- Length is 7 characters or greater.
- Must include at least 1 numeric digit (0 through 9).
- Must include at least 1 special character (for example, !, $, #, @).
You must read and agree to the terms in the following notice:
MEDICAL PROVIDERS CERTIFICATE OF AUTHORITY
NOTICE OF CONFIDENTIALITY
This Medical Providers Certificate of Authority and Notice of Confidentiality is Authorized and Confirmed, between the Medical Benefit Plan Sponsor, as authorized by the Contract Administrator and the Medical Provider as evidenced by this Certificate of Authority. The Plan Sponsor, through the Contract Administrator, hereby authorizes and grants secured access to the Medical Provider, for the purpose of managing specific information concerning the Plan and Plan Participants as outlined in this Notice of Confidentiality.
The purpose of this authorization is to allow the Medical Provider to facilitate the functions of a caregiver in providing services to the Plan Member and their Dependents. Information obtained from the Plan shall be disclosed and used only for the purpose of treatment, payment, administration and facilitation of providing medical services to the Plan Member and their Dependents and for plan administration or as otherwise permitted by any federal law, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and/or any State laws governing the use and disclosure of health related information.
Reasonable care and safety shall be maintained at all times to safeguard and protect the rights of all Plan Members and their Dependents in the handling of all plan information including medical claims, payments and the transfer and disclosure of personally identifiable health information.
The Medical Provider agrees to keep in strict confidence, all such information obtained through the Plan and to use such information solely for the purpose as stated herein. The Medical Provider agrees that any and all such information is and shall remain the confidential information of the Plan Member and their Dependents and that the information obtained shall not be disclosed to any third party except for the purposes as stated herein.