• EMPLOYERS (eMCHCP)
• PRODUCERS
• PUBLIC ENTITY MEMBERS
• STATE MEMBERS

Member Rights Forms

MCHCP has four forms which apply to HIPAA. You may view and print the forms here or request a form by calling our Customer Service Department at 800-487-0771.

All forms must be notarized to be valid, except for the Member Record Amendment/Correction form.

• General Authorization to Release PHI to Designee

  Allows MCHCP to release specific health and medical information to a named party for a given condition or a limited time period. A power of attorney overrides the designee listed on this authorization form.

• Authorization to Release Protected Health Information

  Allows you to authorize MCHCP to release information to a named individual.

• Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication

  Allows you to request that certain information be restricted and allows you to request that MCHCP only communicate with you at a certain location or in a specific manner.

• Member Record Amendment/Correction

  Allows you to request a correction or amendment be made to your file with MCHCP.