Departments

Health Insurance Information

Table Of Contents:
Description:
You will find links below for each item listed.  If you have questions, please contact the Personnel Office.
Documents:
HIPAA Authorization (PDF - 382.6 KB)
Please click the link above for a copy of the “Authorization to Designate form from Excellus BC/BS.

 

In order to allow another to discuss information with Excellus BC/BS and the Franklin County Personnel Office, the Authorization to Designate form must be completed for each relevant member and dependent.

                        ▪ The individual (employee, spouse or dependent) seeking to designate another individual to discuss his/her health records must complete Part A as the Member.  The individual being authorized to discuss health matters is listed in Part B of the form.

                        ▪ In Part C and Part D, please make sure to check the appropriate box(es).  Any boxes that are not checked, Excellus BC/BS will not release any information to your designee about these medical issues.

                        ▪ In Part E, please make sure to sign and date the form for proper processing.

As a reminder, if these forms are not filed with the Personnel Office or Excellus BC/BS, neither office will be able to discuss any health information regarding your coverage, claims, benefit information, etc.   with anyone other than the covered individual.

 

If you are not able to print the forms, please contact the Personnel Office.  Once completed, please return the form to our office or the address listed on the bottom of the form. 

Please feel free to contact the Personnel Office at (518) 481-1665.

            Franklin County Retirees under The Hartford Plan

Even though you are with The Hartford, your eyeglass and hearing coverage is still provided through Excellus BC/BS.  As such, a HIPAA Form would be necessary for a designee to discuss vision or hearing coverage with Excellus BC/BS and/or Franklin County Personnel Office.

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