Access To Records Request

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Access To Records Request

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.

Consider the following when requesting access to your records:

  • You may ask to review and/or obtain information about yourself from records that the Michigan Department of Community Health (MDCH) maintains. The records MDCH maintains are limited to services provided by MDCH programs. If you are seeking medical records, you should ask your physician.

  • The MDCH may deny access to any information if given to MDCH by someone other than a health care provider, under the promise of confidentiality.

  • The MDCH can deny or limit your access to information in certain limited circumstances. You may be asked to contact your direct care provider to access psychotherapy notes or other treatment information if your direct care provider created the original record.

  • If you are denied access to your information, you will be told why. You may request a review of the denial.

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

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)



Individual’s Name at the time the service was provided, if different from above

Individual's Date of Birth


      /       /      

Street Address




Zip Code

Telephone Number




(       )       -      

Records Requested for Access (Identify type and amount of information, including dates where appropriate)



You may request that records be sent to you (or your designee) by email, fax, or U.S. mail. Please note that not all records are available electronically. Only records that are readily producible in electronic format will be sent electronically. Please specify below how you prefer to receive the records requested.



 U.S. Mail

Send Records To (Specify Individual if different from individual whose records are being requested)


Street Address




Zip Code

Telephone Number




(       )       -      

Email Address

Fax Number


(       )       -      

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



You have the following rights to access your information:

  • You have a right to have an answer to your request within 30 calendar days.

  • If there are delays in getting you the answer, you will be told of the delay.

  • The delay cannot be more than 30 calendar days.

  • You will receive an answer in writing.

  • You may be charged a reasonable cost-based fee.

  • Your request may be denied in certain limited circumstances.

Send the completed form to:

Privacy Office, MDCH

201 Townsend Street, 7th Floor

Lansing, MI 48913

Fax: 517-241-1200


You have the right to file a privacy complaint:

Individuals can file privacy complaints with either MDCH or the U.S. Department of Health and Human Services, Office of Civil Rights. You will not be penalized for filing a complaint.

Privacy complaints may be directed to either of the following:

Privacy Officer

Michigan Department of Community Health

201 Townsend Street

Lansing, MI 48913


Region V, Office of Civil Rights

U.S. Department of Health and Human Services

233 N. Michigan Ave., Ste. 240

Chicago, IL 60601




800-649-3777 or 711

Phone: TTY:






MDCH Use Only


Date: / /


Date: / /


Date: / /

Will act by: / /


MDCH Representative Signature


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-1226 (10/14) Page of

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