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. Relationship to Blue Cross and Blue Shield Association HCA, on behalf of itself and its members, hereby expressly acknowledges that this contract constitutes an agreement solely between HCA and Regence BlueShield, an independent corporation operating under a license from the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans (the “Association”), permitting the contractor Regence BlueShield to use the Washington license for those counties designated in its service area. Right to receive and release needed information Regence BlueShield may need certain facts about your health care coverage or services provided to process your claims correctly. Regence may get these facts from or give them to other organizations or persons without your consent. You must give Regence any facts necessary for processing of claims to get benefits under this plan. See page 148 for more information about the confidentiality of your health information. Right of recovery The plan has the right to a refund of incorrect payments. The plan may recover excess payment from any: • Person that received an excess payment. • Person on whose behalf an excess payment was made. • Other issuers of payment. • Other plans involved. Limitations on liability In all cases, you have the exclusive right to choose a health care provider. Since neither UMP nor Regence BlueShield provides any health care services, neither may be held liable for any claim or damages connected with injuries you may suffer while receiving health services or supplies provided by professionals who are neither employees nor agents of either UMP or Regence BlueShield. Neither 2024 UMP Classic (PEBB) Certificate of Coverage 149