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Sample HIPAA Documents for Benefit Funds

If Benefit funds offer health-related benefits to their members, they are most likely subject to the Privacy and Security rules of the Health Insurance Portability & Accountability Act of 1996 ("HIPAA").

HIPAA compliance is rather involved, and may require that covered entities such as benefit funds take a number of actions to comply with HIPAA rules. NYSUT Member Benefits is pleased to make available sample HIPAA Privacy & Security templates to assist benefit funds with their HIPAA compliance efforts.

Please keep in mind that these templates should only serve as general guidance. Benefit funds should consult with their legal counsel to determine exactly what is required under HIPAA in their particular circumstances, as HIPAA rules differ depending upon a number of different factors relevant to a benefit fund's unique operations.

Click on each item to view the template (you will need Microsoft Word to view and edit these files):

Amendment to Benefits Booklet and Declaration of Trust

Certification to Group Health Plan

Certification to Insurance Carrier

Business Associate Agreement

Privacy Notice

Privacy Policies and Procedures

Security Policies and Procedures

HIPAA Privacy Forms Various


NYSUT Member Benefits does not and cannot provide investment, financial, legal, or tax advice, and the information contained herein should not and cannot be construed as such. NYSUT Member Benefits strongly encourages its participants and benefit funds to seek guidance from their own investment, financial, legal, or tax advisors.