Authorization to Disclose Protected Health Information

New rules that help to protect the privacy of your medical records took effect April 14, 2003.

The rules, which are part of the Health Insurance Portability & Accountability Act (HIPAA), restrict access to protected health information by anyone not involved in treatment, payment or health care operations without the patient's permission.

Protected health information is information that is identifiable to an individual. Some examples of individual identifiers are:

• Name
• Address
• Telephone numbers
• Birthdate
• Medicaid ID number and other medical record numbers
• Social Security number
• Name of employer

In most instances, the Department must have the individual's authorization in order to disclose their health information. The HIPAA law lists specific requirements that an authorization form must meet. Individuals that request the disclosure of their protected health information are urged to use the following authorization form that meets HIPAA requirements.

DCH 1183: Authorization to Disclose Protected Health Information  PDF version

DCH 1183: Authorization to Disclose Protected Health Information  MS Word fill-in enabled version

Note: You can complete this version of the form on-line, but you must print the completed form and sign it before submitting it to the Department.

Send your signed, completed form to the Department at:

Michigan Department of Community Health
P.O. Box 30479
Lansing, Michigan 48909-7979

OR

Fax:  (517) 241-8556