pay for those services and supplies. In addition, the plan does not prevent or discourage you from talking about other health plans with your provider. Confidentiality of your health information The plan follows the UMP Notice of Privacy Practices, available online on the HCA website at hca.wa.gov/ump-privacy or by contacting UMP Customer Service. The plan will release member health information only as described in that notice or as required or permitted by law or court order. How to designate an authorized representative TIP: Because of privacy laws, the plan usually cannot share information on appeals or complaints with family or other persons unless the member is a minor, or the plan has received written authorization to release personal health information to the other person. In most cases, the plan must have written authorization to communicate with anyone but the member. However, a parent or legal guardian may act as a representative for a member under age 13 without written authorization, except for issues involving contraceptive use. For members ages 13 to 17, a parent or legal guardian may usually act as a representative, except for certain specially protected types of information, for which the plan must receive written authorization as described below. You may choose to authorize a representative to: • Communicate with the plan on your behalf regarding an appeal in process. • Share your protected health information. • Talk to the plan about claims or services. To authorize release of protected health information, you must complete an Authorization to Disclose Protected Health Information form. The forms for medical and prescription drug appeals are different. To get the forms, follow the instructions below: • Medical benefits: Contact UMP Customer Service or use your Regence account (see Directory for link and contact information). • Prescription drug benefits: Contact WSRxS Customer Service or download the UMP (WSRxS) Prescription drug complaints and appeals form by visiting forms and publications at hca.wa.gov/ump-forms-pubs. Send the form to the address on the form. UMP cannot share information until we receive the completed form. On the form, you must specify: • What information may be disclosed; • The purpose of the disclosure (e.g., receiving an outcome of an appeal); and • Who is designated to receive or release the information. Release of information The plan or HCA may require you to give information when needed to determine eligibility, administer benefits, or process claims. This could include medical and other records. The plan could deny coverage if you do not provide the information when requested. 2024 UMP Select (PEBB) Certificate of Coverage 139