Document 12211881

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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
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