An Individual's Rights under HIPAA

• Access to Records Request

This records request form concerns records maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

• Request for Review of Denial of Access to Protected Health Information

• Request for Amendment of Health Record

This form may be used to request an amendment of your health record if maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

• Accounting of Disclosures Request

This list request form concerns records maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

NOTE: See limitations on form.

• HIPAA Privacy Complaint

A privacy complaint filed with this form is appropriate for records maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

• Confidential Communications Request

This request form concerns records maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

NOTE: See limitations on form.

• Request for Restriction of Use and Disclosure

This records request form concerns records maintained by Medicaid, other medical assistance programs, state facilitites, and any other component of MDCH that is subject to the HIPAA privacy regulations.

NOTE: See limitations on form