An Individual's Rights under HIPAA

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

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

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

NOTE: See limitations on form.

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

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

NOTE: See limitations on form.

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

NOTE: See limitations on form