"Request for Beneficiary Access to Protected Health Information" - Mississippi

Request for Beneficiary Access to Protected Health Information is a legal document that was released by the Mississippi Division of Medicaid - a government authority operating within Mississippi.

Form Details:

  • Released on March 13, 2015;
  • The latest edition currently provided by the Mississippi Division of Medicaid;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Division of Medicaid.

ADVERTISEMENT
ADVERTISEMENT

Download "Request for Beneficiary Access to Protected Health Information" - Mississippi

Download PDF

Fill PDF online

Rate (4.4 / 5) 10 votes
Request for Beneficiary Access to Protected Health Information
Mississippi Division of Medicaid, Privacy Officer
Walter Sillers Building
550 High Street, Suite 1000
Jackson, MS 39201
Toll-free: (800) 421-2408 | Phone: (601) 359-6050
Si necesita esta información en español, por favor llame 1-800-421-2408
Under the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996, you have the right to request the
opportunity to inspect and obtain a copy of your protected health information (“PHI”). The Mississippi Division of
Medicaid (“DOM”) will evaluate your request and either grant it or explain the reason why it will not be granted. Your
right to access does not extend to:
1.
Psychotherapy notes;
2.
Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
3.
PHI that is contained in records that are subject to the Privacy Act, 5 U.S.C. 552a, if the denial of access under the Privacy Act would meet the
requirements of that law;
4.
PHI obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be
reasonably likely to reveal the source of the information;
5.
Access to PHI that a licensed health care professional has determined, in the exercise of professional judgment, is reasonably likely to
endanger the life or physical safety of you or another person;
6.
PHI that makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has
determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other
person; or
7.
Requests for access made by your personal representative and a licensed health care professional has determined, in the exercise of
professional judgment, that the provision of access to the personal representative is reasonably likely to cause substantial harm to you or
another person.
I, ___________________________________________________________________________________,
(Applicant/Beneficiary’s name – first, middle, last, maiden)
hereby request access to my Protected Health Information as indicated below:
Scope of access requested:
All records
Only records related to:
___________________________________________________________
Only records from (enter dates):
________________________ to _________________________
Type of access requested: (continued on next page)
Inspection. Please let me know when I may come to inspect the records and the amount of any charges. I
understand that a DOM staff member will be present and that I may not make any marks or alter the records in any
way. I also understand that DOM may charge me for reasonable clerical costs incurred in making the records
available for inspection at a rate of $10.00 per hour or any part of any hour, and the rate of $40.00 per hour or any
part of any hour for professional staff time. I may be required to pay these costs before I inspect the records.
Copies. I would like copies of all records requested. I understand that DOM may charge me a reasonable fee of up to
$0.50 per page for copies (single sided), $1.25 per page for FAX copies, $7.00 per CD, or other possible costs for
supplies or postage.
 I would like the information in the following form/format (specify paper, electronic, CD, or etc.):
______________________________________________________________________________
Choose one:
 I will pick up the requested copies on ____________________ (mm/dd/yyyy).
Page 1 of 2
Revised 03/13/2015
Request for Beneficiary Access to Protected Health Information
Mississippi Division of Medicaid, Privacy Officer
Walter Sillers Building
550 High Street, Suite 1000
Jackson, MS 39201
Toll-free: (800) 421-2408 | Phone: (601) 359-6050
Si necesita esta información en español, por favor llame 1-800-421-2408
Under the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996, you have the right to request the
opportunity to inspect and obtain a copy of your protected health information (“PHI”). The Mississippi Division of
Medicaid (“DOM”) will evaluate your request and either grant it or explain the reason why it will not be granted. Your
right to access does not extend to:
1.
Psychotherapy notes;
2.
Information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding;
3.
PHI that is contained in records that are subject to the Privacy Act, 5 U.S.C. 552a, if the denial of access under the Privacy Act would meet the
requirements of that law;
4.
PHI obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be
reasonably likely to reveal the source of the information;
5.
Access to PHI that a licensed health care professional has determined, in the exercise of professional judgment, is reasonably likely to
endanger the life or physical safety of you or another person;
6.
PHI that makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has
determined, in the exercise of professional judgment, that the access requested is reasonably likely to cause substantial harm to such other
person; or
7.
Requests for access made by your personal representative and a licensed health care professional has determined, in the exercise of
professional judgment, that the provision of access to the personal representative is reasonably likely to cause substantial harm to you or
another person.
I, ___________________________________________________________________________________,
(Applicant/Beneficiary’s name – first, middle, last, maiden)
hereby request access to my Protected Health Information as indicated below:
Scope of access requested:
All records
Only records related to:
___________________________________________________________
Only records from (enter dates):
________________________ to _________________________
Type of access requested: (continued on next page)
Inspection. Please let me know when I may come to inspect the records and the amount of any charges. I
understand that a DOM staff member will be present and that I may not make any marks or alter the records in any
way. I also understand that DOM may charge me for reasonable clerical costs incurred in making the records
available for inspection at a rate of $10.00 per hour or any part of any hour, and the rate of $40.00 per hour or any
part of any hour for professional staff time. I may be required to pay these costs before I inspect the records.
Copies. I would like copies of all records requested. I understand that DOM may charge me a reasonable fee of up to
$0.50 per page for copies (single sided), $1.25 per page for FAX copies, $7.00 per CD, or other possible costs for
supplies or postage.
 I would like the information in the following form/format (specify paper, electronic, CD, or etc.):
______________________________________________________________________________
Choose one:
 I will pick up the requested copies on ____________________ (mm/dd/yyyy).
Page 1 of 2
Revised 03/13/2015
 Please send the requested copies to (list mailing address, email, or fax number): _____________
Charges:
I hereby agree to pay any reasonable costs or fees, as specified above. Please bill me (once payment is received, the
records will be released).
Please contact me to let me know the total cost that I will incur.
Signature: By signing below, I hereby swear and affirm that the above statements are true and correct to the best of my
knowledge.
______________________________________
_______________________________________
(Applicant/Beneficiary’s Name)
(Date of birth – mm/dd/yyyy)
______________________________________
_______________________________________
(Social Security Number – xxx-xx-xxxx)
(Medicaid Identification Number)
_____________________________________________________________________________________
(Mailing address)
______________________________________
_______________________________________
(Telephone number)
(E-mail address)
______________________________________
_______________________________________
(Signature**)
(Date signed – mm/dd/yyyy)
**If not signed by the Applicant/Beneficiary, please indicate your relationship to the Applicant/Beneficiary and attach any required
documentation confirming your authority to act for the Applicant/Beneficiary________________________________
To get a copy of DOM’s Notice of Privacy Practices, visit http://www.medicaid.ms.gov/Publications.aspx, contact a DOM
Regional Office, or contact DOM at the above address or telephone number.
For official DOM use only:
Date request received:
Received by:
Request:  Granted  Denied
Granted/denied by (Print Name):
Title:
Request:  Mailed  Given In Person  Faxed
Signature of DOM Representative:
Date (mm/dd/yyyy):
Date (mm/dd/yyyy):
If Inspection Requested
Date of Inspection (mm/dd/yyyy):
Fees Accessed:
Reconsideration:  Granted  Denied
Granted/denied by (Print Name):
Title:
Signature of DOM Representative:
Date (mm/dd/yyyy):
Comment(s) and Action(s) Taken:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
Page 2 of 2
Revised 03/13/2015
Page of 2