HIPAA Coverage

Forms

• Personal Representative Appointment
• Authorization
• Confidential Communication
• Restriction Request

You will need Adobe Acrobat Reader to open these forms.

Send completed and signed documents to:

Mail:
First Administrators, Inc.
Compliance Dept.
P.O. Box 8150
Rapid City, SD 57709-8150

Fax:
Attention: Compliance Dept.
Number: (605) 399-7950

Email:
FAIComplianceTeam@firstadministrators.com