Request For Review of Denial of Access




Yüklə 19.47 Kb.
tarix11.03.2016
ölçüsü19.47 Kb.



Request For Review of Denial of Access

To Protected Health Information


Directions: Type or print all requested information with exception of signatures.

I request a review of MDCH’s decision to deny me access to my Protected Health Information. I made the request for access on the date(s) below:




     
















Name of Facility or MDCH program that maintains the individual's records




     
















Individual's Name (Beneficiary, Recipient, Patient, Consumer, etc.)

Individual's ID Number (Medicaid, SSN, Other)

     

     

Street Address

Individual's Date of Birth

     

   /    /     

City

State

ZIP

Phone

     

  

     

(     )     -     







Legal Representative's Name (If applicable)

Legal Representative's Relationship to Individual (A letter of authority may be requested.)

     

     

Signature of Individual or Legal Representative

Date

     

   /    /     

MDCH Use Only

Previously withheld information to be provided to the individual:

 All  Part  None

Date Received

/ /


Reason for withholding information:

Name of Privacy Office Member and Title:

Name of Health Care Practitioner:

Date: / /

AUTHORITY: This form is acceptable to the Michigan Department of Community Health as compliant with HIPAA privacy regulations, 45CFR Parts 160 and 164 as modified August 14, 2002.
The Michigan Department of Community Health is an equal opportunity employer, services and programs provider.

DCH-1227(E) (8/13)


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə