Requesting Confidentiality Patient Script
Follow these steps to request confidentiality from your health insurance plan for your Summary of Payment (SOP) form
1. Find your health insurance plan's name and policy number. Both can be found on your health insurance card.
2. Call the customer service number on the back of your health insurance card or on your health insurance plan's website.
3. You can then use this script to help you make the request:
- Hello, my name is _________.
- My policy number is #_________ [state your policy number]
- I am covered under my [parent’s/spouse’s] health insurance policy.
- Under Massachusetts’ new Act to Protect Access to Confidential Health Care, which is now in effect, I can change where my Summary of Payments form is sent, so you don’t send information about my health services to my [parents/spouse].
- I would prefer that my SOP was sent to me through ______________ [state chosen option: mail or online insurance patient portal] at the following address _______ (if applicable).
- Please let me know if I need to take any further action or how to put my request in writing if necessary.
- Please provide confirmation after my request form has been processed. You can send me confirmation through ______________ [state chosen option: phone, email, mail, or online insurance patient portal]. My contact information is ___________.
- Thank you!