HIPAA Disclosure Agreement

You must agree to this “Health Plan Claims Status Lookup Tool Agreement” before using this web-based form. Please read the terms of this agreement as follows:

Protected Health Information as defined under the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act acquired or used by Health Plan of San Joaquin/Mountain Valley Health Plan ("Health Plan") regarding any patient or health plan beneficiary, physician, or other health care provider
Conﬁdential information may be disclosed only to persons or entities having a right to obtain access under applicable law or whose contractual relationship with Health Plan provides for such access. Access or use of protected health information should be limited to the minimum necessary to accomplish the task or purpose for which access is authorized.
Medical information identifiable by patient, in addition to being confidential information, is subject to state and federal laws and regulations respecting the maintenance of confidentiality. All persons employed by the purchasing entity shall abide and be bound by such laws and regulations.
Records or materials, whether in written or electronic form, containing confidential information, may not be removed from Health Plan offices.
I have read and will abide by the confidentiality policies in this agreement.
I understand that Health Plan reserves the right to continuously monitor and audit user access and that attempts to circumvent Health Plan security policies and procedures will constitute violation of this confidentiality statement resulting in actions including, but not limited to, the revocation of access to the DRE portal or web-based forms or resources. Health Plan follows the HIPAA Enforcement Rules and any violations of HIPAA regulations can result in penalties including, but not limited to civil penalties.
I understand that I should remember to log out and close my browser when I am finished accessing this web-based portal/form. This prevents someone else from viewing information if I leave, share, or use this computer that I am using to access this form.

Contact Information / Provider Office

First Name

Last Name

Phone Number

Billing Provider Name

Billing Provider NPI

I have read and will abide by the confidentiality policies as described above. I attest that as a provider, supervisor, manager or administrator of this medical group or office, I have full managerial oversight of administrative processes involving the exchange of patient information and compliance with confidentiality protocols. I further attest that in order to obtain access to Health Plan's web based forms or other resources—e.g. OHC Claims Look-up Tool, Claims Status Look-up Tool, ect.—I am: a) employed or contracted with this organization, who b) requires access to Health Plan OHC Claims Status Lookup form in order to complete their job functions.

Do you attest?

I Attest.I do not Attest.

Date

Note: Please agree to the HIPAA Disclosure Agreement terms to use start using the Claims Status Lookup Tool. If you do not agree to the terms please click here to go back to the Non-Contracted Provider page.