Free Microsoft Word - Member Access Request1.DOC - Indiana

Indiana Health Coverage Programs

M E M B E R

A C C E S S

R E Q U E S T

Section A: IHCP Member Requesting Access
Name: Address: City, State, ZIP Code: IHCP RID Number: Address: City, State, ZIP Code: Phone Number: Social Security Number:

Check this box, and complete the information below, if you want your health information records mailed to a different address.

Section B: To the member ­ Please read the following and complete the information requested
You have the right to inspect and obtain a copy of your health information maintained by the Indiana Health Coverage Programs (IHCP). You are not, however, entitled to inspect or copy information used for lawsuits, criminal investigations or prosecutions, notes made by a mental health therapist or psychiatrist, and certain other records. Please complete this form to request access to your health records maintained by the IHCP. Specify the records, and the dates of the records to be inspected or copied:

I want to inspect these records. Do you want us to mail the copies?

I want to obtain copies of 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 your or your personal representative, you must provide us with a signed authorization. We can supply you with the appropriate authorization form.

Section C: To the member ­ Please sign the form and complete the appropriate information Signature: Date:

Section D: To the member's personal representative ­ Please sign the form and complete the appropriate information
If this request is from a personal representative on behalf of the IHCP member, please provide a copy of the documentation to support the representation and complete the following: Personal Representative's Name: Relationship to IHCP Member: This form must be notarized if submitted by the member's personal representative. Subscribed and sworn (affirmed) before me this day of Signature: Notary Public in and for the state of In the county of (Affix seal) My commission expires: , Date:

Please mail this completed form to the following address: IHCP Privacy Office P.O. Box 7260 Indianapolis, IN 46207-7260
State Form 51737 (5-04)/OMPP 0052