HIPAA forms

Because Fallon Health is dedicated to protecting your privacy, we are strict about who can see your information. That's why we provide these forms for you to let us know how you want your information managed.

For our commercial members

Personal Representative Authorization form 
This form is for Fallon Health members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.

For our MassHealth members

Personal Representative Authorization Form
This form is for Fallon MassHealth members to give permission to Fallon to disclose your personal information to a designated person and/or to give permission to someone else to file an appeal on your behalf.

For all members (as appropriate)

Amendment Request for Personal Information form
This form is used to ask us to make changes to your record if you think it is inaccurate or incomplete. You do not need to use this form for corrections to your address, date of birth or name.

Authorization for Release of Personal Information form
This form authorizes Fallon Health to give your personal information to another individual or entity (such as your employer, if they are working on your behalf to resolve a claim issue).

Request for an Accounting of Disclosures of Personal Information form
This form is used to request a listing of who Fallon Health has shared your information with for reasons other than treatment, payment or health care operations. Please note there are limitations to the number of prior years you may request.

Restriction form
This form is used to put limitations on how we use or share your personal information.

For our Fallon Medicare Plus and NaviCare members

For Fallon Medicare Plus and NaviCare members, please visit the forms page for Fallon Medicare Plus and the forms page for NaviCare.