Member Rights Forms
MCHCP has four forms which apply to HIPAA. You may view and print the forms here.
All forms must be notarized to be valid, except for the Member Record Amendment/Correction form.
- Authorization to Release Protected Health Information
- Allows you to authorize MCHCP to release information to a named individual.
- 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. List member and/or subscriber’s name and Social Security number, mailing address, and daytime and evening phone numbers. Indicate the authorized individuals.
- Must be signed by the member or the person authorized by law to act for the member. This signature must be witnessed by a notary and does require a notary’s seal or stamp to be valid.
- A power of attorney overrides the designee listed on this authorization form.
- This authorization remains in effect as long as you are an MCHCP member. Please notify MCHCP if you would like to make changes.
- Member Record Amendment/Correction
- Allows you to request a correction or amendment be made to your file with MCHCP.
- 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.