Legal Documents

Below are legal documents related to the FEDVIP program.

FEDVIP rules and regulations

The U.S. Office of Personnel Management (OPM) has issued regulations to administer the Federal Employee Dental and Vision Benefits Enhancement Act of 2004, which was enacted December 23, 2004.

Third party authorization

BENEFEDS (a unit of Long Term Care Partners, LLC) can't give information about your FEDVIP plans to anyone other than you, your insurance carrier and payroll/annuity provider unless you complete and submit an authorization form allowing such disclosure. We protect your plan information, which may be considered Personally Identifiable Information (PII), from unauthorized disclosure.

To give us permission to disclose your plan information to someone you designate, complete an Authorization of Disclosure Form and fax it or mail it to us at the address below. This authorization form concerns your personal records and only you or your legal representative (such as a power of attorney, guardian or conservator) can sign it.

You don't have to complete this form — it's completely voluntary. However, if you don't complete and submit the form we can't disclose any information about your FEDVIP plan to a person of your choice, not even your spouse, another relative or a benefits person from your agency or retirement system.

You can revoke a submitted form at any time by notifying us in writing at the address below. Revoking this authorization will have no effect on any information released in reliance on this authorization before BENEFEDS received your notice to revoke the authorization.

Power of attorney (POA)

If a POA is received by BENEFEDS from an enrollee or from an enrollee's agent (i.e. attorney-in-fact), BENEFEDS will review the POA (or other legal document) to determine if it is applicable for use with regard to the enrollee's BENEFEDS account.

This form is to certify that a power of attorney executed by an individual remains in effect. The form must be signed in the presence of a notary public by the acting attorney-in-fact or agent appointed in the power of attorney on file with BENEFEDS. POA and other legal documents will be approved upon receipt by BENEFEDS.

Fax and address

Authorization of Disclosure forms including revocations, POA forms and affidavits should be faxed to 603-433-3811 or mailed to:

ATTN: HIPAA Privacy Office
P.O. Box 797
Greenland, NH 03840-0797

Public Burden Statement

The public reporting burden for this collection is estimated to average 8 minutes for a respondent to submit an enrollment, including time for reviewing education and support content but not including time for reviewing a plan and specific benefits. The total burden hour estimate for this form is 44,307 hours. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Healthcare and Insurance, Attn: OMB Number (3206-0272), 1900 E Street NW, Washington, DC 20415-7900. You are not required to respond to this collection of information unless a valid OMB control number is displayed.