Free June 24, 1999 - Indiana

Date Member Name Member Address City, State Zip code Subject: Request to access or copy Indiana Health Coverage Programs (IHCP) records Dear Member: We are denying your request, received on {Date}, to inspect or obtain copies of your records. We have denied your request for the following reasons: We do not have the requested records. We do not know who may have the requested records. You may be able to obtain the requested records from the following: {Response, such as Dr. Sue Smith or Acme Hospital}. The records you requested cannot be accessed for inspection or copying because they are being used for lawsuits, criminal investigations or prosecutions, they are notes made by a mental health therapist or psychiatrist, or certain other records. The records you requested were obtained in confidence from a source other than a health care provider and providing you access to these records is likely to reveal the confidential source. A licensed health care professional has determined that providing you or your personal representative access to these records is likely to endanger the physical safety or life of you or another, or that the records contain references to persons other than health care providers whose physical safety or life may be endangered if the access you request was granted. If you disagree with the determination of the licensed health care professional, you can ask us to designate a different licensed health care professional who did not participate in the determination to deny you access to review your records. Please contact the IHCP Privacy Office at xxx-xxxxxxx to request such a review. You can file a complaint about the denial of your access request with the IHCP Privacy Office or with the Secretary of the United States Department of Health and Human Services. Contact the IHCP Privacy Office about the procedure for complaining to us, or to the Secretary of Health and Human Services. If you have questions, wish to discuss the denial, or file a complaint, please contact the IHCP Privacy Office at xxx-xxx-xxxx.

Sincerely,

IHCP Privacy Office

State Form 51731 (5-04)/OMPP 0046