Privacy and Confidentiality

REQUEST TO REVOKE CONFIDENTIAL COMMUNICATIONS

You have the right to revoke the alternate address that you are currently having protected health information sent to.

The steps to revoke confidential communications:

1. Obtain a Withdraw Previous Authorization Form by clicking on this link or by calling Customer Service for this form at the telephone number on the back of your identification card.

2. Complete this form including all pertinent information.Please note that Carolina Care will not be able to process an incomplete form and you will NOT BE NOTIFIED if this situation arises.

3. Sign the completed form and send to:

Carolina Care Plan PO. Box 100234 Columbia, SC 29202-3234

NOTE: If you obtained your form at our website, please print it out when completed. All requests must have a signature and be sent to the address above. Requests will not be excepted if sent via email.

4. When your request is received, the necessary steps will be taken by the Carolina Care Staff to send you the information in a reasonable time frame.

NOTE: You may send your request in writing instead of using the Privacy & Confidentiality Form, but the request must include: your name, your birthday, the policy number under which you are covered, the group number under which you are covered, your social security number, the information you would like to access and the dates of information you would like to see (if applicable). Again, please note that Carolina Care will not be able to process a request that does not include all the necessary information and you will NOT BE NOTIFIED if this situation arises.