ࡱ> a ibjbjzz .P\P\QI   8D\$ j4tz>"T"T"T"/#(W$$Lq3s3s3s3s3s3s3$5837%/#/#7%7%3T"T"$4?*?*?*7%RT"T"q3?*7%q3?*?*V1@2T"6%F 2 ]3:40j42x89%b8928927%7%?*7%7%7%7%7%331(7%7%7%j47%7%7%7%897%7%7%7%7%7%7%7%7%> : ACCESS TO RECORDS REQUESTMichigan Department of Health and Human ServicesThis records request form concerns records maintained by Medicaid, other medical assistance programs, state facilities, and any other component of MDHHS that is subject to the HIPAA Privacy Regulations.Consider the following when requesting access to your records:You may ask to review and/or obtain information about yourself from records that the Michigan Department of Health and Human Services (MDHHS) maintains. The records MDHHS maintains are limited to services provided by MDHHS programs. If you are seeking medical records, you should ask your physician. The MDHHS may deny access to any information if given to MDHHS by someone other than a health care provider, under the promise of confidentiality. The MDHHS can deny or limit your access to information in certain limited circumstances. You may be asked to contact your direct care provider to access psychotherapy notes or other treatment information if your direct care provider created the original record. If you are denied access to your information, you will be told why. You may request a review of the denial.Directions: Type or print all requested information with exception of signatures.Name of Facility or MDHHS program that maintains the individuals records FORMTEXT      Individual s name (beneficiary, recipient, patient, consumer, etc.)Individual s ID number (Medicaid, SSN, other) FORMTEXT       FORMTEXT      Street addressIndividual s date of birth FORMTEXT       FORMTEXT      CityStateZIP codePhone FORMTEXT       FORMTEXT     FORMTEXT       FORMTEXT    - FORMTEXT    - FORMTEXT     Records requested for access (Identify type and amount of information, including dates where appropriate. For newborn screening results, provide the mother s name at the time of birth) FORMTEXT       FORMTEXT      You may request that records be sent to you (or your designee) by email, fax, or U.S. mail. Please note that not all records are available electronically. Only records that are readily producible in electronic format will be sent electronically. Please specify below how you prefer to receive the records requested. FORMCHECKBOX  Email FORMCHECKBOX  Fax FORMCHECKBOX  U.S. MailSend records to (specify individual if different from individual whose records are being requested) FORMTEXT      Street address FORMTEXT      CityStateZIP code FORMTEXT       FORMTEXT       FORMTEXT      EmailFax number FORMTEXT       FORMTEXT      Legal representative s nameLegal representative s relationship to individual (A letter of authority may be requested) FORMTEXT       FORMTEXT      Signature of Individual or legal representativeDate FORMTEXT      You have the following rights to access your information: You have a right to have an answer to your request within 30 calendar days. If there are delays in getting you the answer, you will be told of the delay. The delay cannot be more than 30 calendar days. You will receive an answer in writing. You may be charged a reasonable cost-based fee. Your request may be denied in certain limited circumstances.Send the completed form to: Privacy Office, MDHHS 333 South Grand Avenue Lansing, MI 48933 Fax: 517-241-1200 Email:  HYPERLINK "mailto:MDHHS-Subpoena@michigan.gov" MDHHS-Subpoena@michigan.govYou have the right to file a privacy complaint:Individuals can file privacy complaints with either MDHHS or the U.S. Department of Health and Human Services, Office of Civil Rights. You will not be penalized for filing a complaint.Privacy complaints may be directed to either of the following: Michigan Department of Health and Human Services PHCS Legal Division, Bureau of Legal Affairs 333 South Grand Avenue Lansing, MI 48933 Phone: 517-284-4844 or 517-284-4849 Fax: 517-241-1200KLMO    \ ]   6 ; ! & W v " # H g 繲wkhGQhGQ\^JaJhGQ\^JaJhN~hGQ5\^JaJhGQhGQOJQJ^JhGQOJQJ^JhN~hGQOJQJ^J hGQhGQh1hGQ5\^Jh-hGQ5\^J h1hGQ h^Jh1hGQ^JhGQ h&hGQh&h&h&5\&LMNm?kdV$$Ifl4,,4 lalf4ytls $IfgdGQ?kd$$Ifl4,,4 lalf4ytls $Ifgd&NO   sg $$Ifa$gdGQ?kd$$Ifl4,,4 lalf4ytls $$Ifa$gd?kd$$Ifl4,,4 lalf4ytls  \ ]  # sbbbb & F(($IfgdGQ?kd$$Ifl4,,4 lalf4ytls $$Ifa$gdGQ?kdX$$Ifl4,,4 lalf4ytls sjjjj $Ifgd(,?kd$$Ifl4,,4 lalf4ytls $$Ifa$gdTi?kd&$$Ifl4,,4 lalf4ytls   2 4 5 ? @   $&(*>@BLNPRnѸ🴔蟴{sohxZhGQhGQ5jjh[`[Ujh[`[UmHnHujh[`[Ujh[`[Uh[`[hGQCJ^JaJh[`[jhGQUmHnHujhGQUjhGQU h^Jh1h^JhGQh(, hGQhGQhGQhGQ^J( 3 4 }=4 $IfgdGQ?kd$$Ifl4 ,,4 lalf4ytls $Ifgd[`[xkd$$Ifl4\ Ca!, #  0 4 lalf4ytls=xkd$$Ifl4\ Ca!, #  0 4 lalf4ytls $IfgdTi?kdv$$Ifl4P,,4 lalf4ytls(P $Ifgd[`[Rkd$$Ifl40","~ 4 lalf4ytls$d`$If^a$gd[`[ $Ifgd[`[PRpPGG $IfgdTiRkdV$$Ifl4 0","~ 4 lalf4ytls $IfgdTiRkd$$Ifl40","~ 4 lalf4ytlsnp ",.02FHJTVXZnprxz|~j hxZUj hxZUj* hxZUj hxZUhGQhxZ5j<hxZUjhxZUmHnHujhxZUjhxZU h[`[hxZhxZ hGQhxZ8". $Ifgd[`[ $IfgdTiRkd$$Ifl40","~ 4 lalf4ytls.0X|}}}t $IfgdxZ $IfgdTixkd( $$Ifl4 \=",=N~ 4 lalf4ytlsLPRȾxphGQhY`5jXhY`U hGQhY`jhY`UmHnHuj4 hY`UjhY`UhY` hGQh[`[hQh[`[hQh[`[5\ hGQhxZj hxZUjhxZUmHnHujh hxZUhxZjhxZU(}=4 $IfgdTi?kd $$Ifl4,,4 lalf4ytQ $IfgdQxkd< $$Ifl4\=",=N~ 4 lalf4ytlsekd $$Ifl4 F+,*    4 lalf4ytls $IfgdTi $IfgdY` $IfgdTiekd$$Ifl4 F+,*    4 lalf4ytlsy9'$($If^a$gdxZ?kd4$$Ifl4,,4 lalf4ytls (($IfgdY`xkd$$Ifl4\ Ca!, #  0 4 lalf4ytlscdefpq  ,.02FɾɳɨɤɤɟɘɅwpɘ hGQhxZjhxZUmHnHujhxZUhGQhxZ5 h[`[hxZ hxZ5hjhxZUj hxZUjhxZUhxZjhxZUhY`hGQhY`OJQJ^JhxZOJQJ\^JhzihY`OJQJ\^J)de~>5 $IfgdTi?kd$$Ifl4 ,,4 lalf4ytls $IfgdxZekd$$Ifl4F,    4 lalf4ytls$($If^a$gdxZ.0XZvm-?kd$$Ifl4,,4 lalf4ytls $IfgdTi?kd$$Ifl4 ,,4 lalf4ytls $IfgdTi?kdn$$Ifl4,,4 lalf4ytlsFHJTVXZbdnpz  "$8:ϵϜϑډς{pjhJl@U h[`[hJl@ hGQhJl@hGQhxZ5jhJl@UjhJl@UjhJl@UmHnHujhJl@UjhJl@U h[`[hxZhJl@ hGQhxZhxZjhxZUmHnHujhxZUj<hxZU,Zdp~~~ $IfgdTiekd$$Ifl4 FC",C ~     4 lalf4ytls $IfgdxZ $IfgdTi  "4Rkd|$$Ifl4 0C,CN4 lalf4ytls $IfgdJl@ $IfgdTiekd$$Ifl4FC",C ~     4 lalf4ytls:<FHJL`bdnprt&(`bdfz|~ "$&:嵫Ҋ|tjhaaU h[`[haa hGQhaahaaj,hJl@UjhM3U h[`[hJl@hJl@@CJaJhJl@hJl@@CJaJhJl@hJl@@ hGQhJl@hGQhJl@5jdhJl@UhJl@jhJl@UmHnHujhJl@U,"Jrtbd>RkdP$$Ifl4 0C,CN4 lalf4ytls $IfgdTi $IfgdJl@Rkd$$Ifl40C,CN4 lalf4ytls $IfgdTi "$L>Rkd$$Ifl4 0","~ 4 lalf4ytls $IfgdTi $IfgdaaRkd$$Ifl40C,CN4 lalf4ytls $IfgdTi:<>HJLN,->?ABCDabxy   µړ||x|x||mfm\mړ|hh0J+>* hhjhhUhh1h1haa5\ hY`5hY` haa5hGQhaaOJQJ^Jh-haa5OJQJ\^Jh-haaOJQJ^Jh1haa5OJQJ\^JhGQhaa5haajhaaUmHnHujhaaUjhaaU$LN-{?@O?kdv$$Ifl4,,4 lalf4ytY` & Fd$Ifgdaa (($IfgdTiRkd$$Ifl40","~ 4 lalf4ytls @ABCD`vm $Ifgdaa?kd>$$Ifl4,,4 lalf4ytP?kd$$Ifl4,,4 lalf4ytP $Ifgd(,`ax g=kd$$Ifl4,,4 lalf4ytY`  V$Ifgd  V$Ifgd1?kd$$Ifl4,,4 lalf4ytY`@Atd$ V$Ifa$gd1=kd$$Ifl4,,4 lalf4ytY`  V$Ifgd1?kdf$$Ifl4,,4 lalf4ytY`Auz<>ddd#d$dRdSdTdodpdrdud?e@eiejekeeeeeeeeeežŦݛ|xxqgxhlshls5\ hls5\hlshTih10J+>*j'!h1h1U h1h1jh1h1Uhh0J+>*jX hhU hhjhhUhU h15\h1 h1^Jh-h1^Jh1h15\ h15&=re  V$Ifgd1?kd$$Ifl4,,4 lalf4ytY`  V$Ifgd1?kd*$$Ifl4,,4 lalf4ytY`=>pddqdrduddddde$e7e$ V$Ifa$gd1$ V$Ifa$gd1=kd$$Ifl4,,4 lalf4ytY` TTY: 800-649-3777 of 711 Email: HYPERLINK "mailto:MDHHS-Subpoena@michigan.gov"MDHHS-Subpoena@michigan.gov OR Region V, Office of Civil Rights US Department of Health and Human Services 233 North Michigan Avenue, Suite 240 Chicago, IL 60601 Phone: 312-368-1019 Fax: 312-886-1807 TTY: 800-537-7697 Email:  HYPERLINK "mailto:OCRComplaint@hhs.gov" OCRComplaint@hhs.gov MDHHS Use Only FORMCHECKBOX  Approved FORMCHECKBOX  Denied FORMCHECKBOX  Delayed Date: FORMTEXT       Date: FORMTEXT       Date: FORMTEXT      Comments: FORMTEXT      MDHHS representative signatureDate FORMTEXT      The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.Authority: This form is acceptable to the Michigan Department of Health and Human Services as compliant with HIPAA privacy regulations, 45CFR Parts 160 and 164 as modified August 14, 2002.     DCH-1226 (Rev. 8-16) Previous edition obsolete.  PAGE 2 7eeeeee@?kd"$$Ifl4P,,4 lalf4ytY` $Ifgd(,ekd!$$Ifl4FV4,V]    4 lalf4ytls$ V$Ifa$gd1eeeeeeeefYL?  /$Ifgdls  e$Ifgdls  V$Ifgdls?kdf#$$Ifl4,,4 lalf4ytls  V$IfgdTi?kd"$$Ifl4,,4 lalf4ytls $$Ifa$gdlseeeeeeeeeeeeeeeeeeeeeeef f ff f4f6f8fBfDfVfXflfnfpfzf|fffffffffffffgh_sCj)hlsUh(,j&hlsUj>&hlsUjhlsUmHnHuj%hlsUj$hlsUjL$hlsU hlshlsj#hlsUhlsjhlsU4eeefffFfHfVf~ffpp``$ @$Ifa$gdls$ ]$Ifa$gdls $Ifgdls$ Y$Ifa$gdlsekd4%$$Ifl4 F,    4 lalf4ytls ffff' $Ifgd(,kd*'$$Ifl4  8 !x*,8%$$$$4 lalf4ytlsffffffff}t $Ifgd_sCxkd<($$Ifl4p\ Ca!, #  0 4 lalf4yt_sC $Ifgd(,fffff}=4 $Ifgd(,?kd *$$Ifl4h,,4 lalf4ytls $Ifgdlsxkd($$Ifl4\ Ca!, #  0 4 lalf4yt_sCffgg g"gJgcZZ $IfgdTiRkd*$$Ifl4 0","~ 4 lalf4ytls $IfgdTi?kdp*$$Ifl4,,4 lalf4yt_sCgggg g"g$g8g:g*B*phcFV F lsFollowedHyperlink >*B*phOrPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. J;̊iN $AI)t2 Lmx:(}\-i*xQCJuWl'QyI@ھ m2DBAR4 w¢naQ`ԲɁ W=0#xBdT/.3-F>bYL%׭˓KK 6HhfPQ=h)GBms]_Ԡ'CZѨys v@c])h7Jهic?FS.NP$ e&\Ӏ+I "'%QÕ@c![paAV.9Hd<ӮHVX*%A{Yr Aբ pxSL9":3U5U NC(p%u@;[d`4)]t#9M4W=P5*f̰lk<_X-C wT%Ժ}B% Y,] A̠&oʰŨ; \lc`|,bUvPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!R%theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   HHHK nF::egi!$'*/7=N P.Z"L@`=7eeeffffJgTgii "#%&()+,-.015689:;<>?@4@F!')5;Yekmy}   $ 4      ) / D P V X d j  E Q W q "2JZeu~ >JPFtFtFtFtFtFtFtFtFtFtFtFtFtG G$G$FtFtFtFtFtFtFtFtFtFtXXXG$G$G$FtFtFtFtFt<CEK!8@0(  B S  ?Text1Text2Text3Text6Text4Text5Check1Text7Text9Text8Text10 _Hlt457829383 _Hlt457829384 _Hlt457484000 _Hlt457484001Check2Text11Text125Z  E $$L @ @ @@Gl   0 W %%[QSTVWYZ\]QSTVWYZ\]g>Ylm~ $    0 2 D W m > D  + W i Rij|}%()JKuw38H\>PQSTVWYZ\]Ylm~3 7 8 9 :    0 D W   , B S T q #XPQSTTVWYZ\]g`"Ŧ>o;& 6X<;9^`B*OJQJo(ph ^`OJQJo(o pp^p`OJQJo( @ @ ^@ `OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( ^`OJQJo(o PP^P`OJQJo(h hh^h`OJQJo(h 88^8`OJQJo(oh ^`OJQJo(h   ^ `OJQJo(h   ^ `OJQJo(oh xx^x`OJQJo(h HH^H`OJQJo(h ^`OJQJo(oh ^`OJQJo(h^h`OJQJo(hH8^8`OJQJ^Jo(hHo^`OJQJo(hH ^ `OJQJo(hH ^ `OJQJ^Jo(hHox^x`OJQJo(hHH^H`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH>o;&g`"X<; <                          -,aa1_)(,UD,M3Jl@_sC3KALFM{MhQxZ[`[!\Y`Y`pAe2gTils- 9XpiQjK \f&(VP*E%)(\GQ QS@ AAAA @(@4@@f@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial?= *Cx Courier New;WingdingsA$BCambria Math"hLRLRHgI $I $r c!4GG > 2QHP?p*!xx Access to Records RequestQuality Assurance Section Jane Boyden   Oh+'04 HT t   Access to Records RequestQuality Assurance Section4DCH-1226E_Access_to_Records_Request_470150_7.dot Jane Boyden2Microsoft Office Word@@t@6@6I՜.+,D՜.+,t0 hp  4Michigan Department of Health and Human Services$ G Access to Records Request Title 8@ _PID_HLINKSAh*Qmailto:OCRComplaint@hhs.gov-]N#mailto:MDHHS-Subpoena@michigan.gov-]K#mailto:MDHHS-Subpoena@michigan.gov  !"#$%&'()*+,-./0123456789:;<=>?@ACDEFGHIJKLMNOPQRSTUVWXZ[\]^_`abcdefghijklmnopqrstuwxyz{|}Root Entry Fi6Data B-1TableYP9WordDocument.SummaryInformation(vDocumentSummaryInformation8~CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q