Free Wisconsin Chronic Disease Program (WCDP) HIPAA Privacy Amendment Request, HCF 13157 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Health Care Financing HCF 13157 (03/05)

STATE OF WISCONSIN P.L. 104-191

WISCONSIN CHRONIC DISEASE PROGRAM (WCDP)

HIPAA PRIVACYAMENDMENT 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 ( )

SECTION II AMENDMENT REQUEST Please read the following and complete the information requested. You have the right to ask for a correction to enrollment, claim, or other records used to make decisions about your health plan services that the Wisconsin Chronic Disease Program (WCDP) or our business associates maintain. The WCDP may decline your request if the information is not part of the protected health information we create, the information requested to be amended is complete and accurate in our assessment, or the information is not accessible to you as a recipient. To exercise your right to request this amendment, please complete this form. Specify the records, and the dates of the records, you wish to amend and the amendments you wish to make:

State the reasons for the amendments:

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