Free Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Access Request, HCF 13154 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13154 (03/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN CHRONIC DISEASE PROGRAM (WCDP)

HIPAA PRIVACY ACCESS REQUEST
The Privacy Rule standards of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) P.L. 104-191 require DHFS, as a covered entity, to implement processes that give patients certain rights regarding individually identifiable health information. The information requested on this form is needed to comply with those Privacy Rule requirements. Provision of the information that is requested on this form is voluntary. Although the use of this version of the form is voluntary, all of the information outlined on this form is mandatory. Personally identifiable information requested on this form is mandatory in order to process your request and will only be used for this purpose. INSTRUCTIONS: Mail this completed form to the following address: WCDP Participant Services PO Box 6410 Madison WI 53716 SECTION I RECIPIENT INFORMATION Name Last, First, Middle Initial WCDP Identification Number

Address Street, City, State, ZIP Code

Telephone Number ( )

Check this box if you want your health information records mailed to a different address. If so, complete the information below. Address Street, City, State, ZIP Code

SECTION II ACCESS POLICY SUMMARY AND REQUEST You have the right to see or copy enrollment, claim, or other records used to make decisions about your health plan services by the Wisconsin Chronic Disease Program (WCDP). WCDP will not include information prepared for legal actions or proceedings, criminal investigations or prosecutions, notes made by a mental health therapist or psychiatrist, and certain other records. Complete this form to request access to enrollment, claim, or other records used to make decisions about your health plan services by the WCDP. Specify the records to be inspected or copied: enrollment claim other (please specify)

Specify the specific timeframe of the records to be inspected or copied: 1 month 3 months I want a copy of these records I want to inspect these records You may be charged a fee for the costs of copying, mailing, or for other supplies needed to fulfill your request. You will be notified of any costs prior to receiving the requested copies. If you want us to provide copies of your records to any person other than you or your personal representative, you must provide us with a signed authorization. We can supply you with the appropriate authorization form. 6 months other

WCDP HIPAA Privacy Access Request HCF 13154 (03/05)

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SECTION III SIGNATURES Please sign the form and complete the appropriate information. SIGNATURE Recipient Date Signed

If this request is from a personal representative on behalf of the recipient, provide a copy of the documentation to support the representation and complete the following: Name Personal Representative Relationship to Recipient

SIGNATURE Personal Representative

Date Signed