Cameron University Health Plan ELECTRONIC NOTICE OF PRIVACY PRACTICES I request to receive the University’s Health Plan NPP via email at the following address: OR I withdraw my request to receive the University’s Health Plan’s NPP via email. I may request a paper copy of the NPP at any time. Name Date Address _____________________________________ Signature File in Member Chart Rev 1/2015 © 2015 HIPAA Document Retain for minimum of 6 years