This notice describes how medical information about you may be used and disclosed by entities covered under the HIPAA privacy rules.
Members should use this form to provide MESSA with written authorization to use, discuss or disclose their PHI with a third party.
Similar to the written authorization form, this form is required for specific authorization to use or disclose psychotherapy notes to MESSA or from MESSA.
Members should use this form to request a summary of disclosures (with a six year maximum) by MESSA of their PHI.
This form is for members to request an amendment to the PHI MESSA maintains.
This form is for members to request a review of the records MESSA maintains containing their PHI.
Members may request that MESSA further restrict the disclosure of their PHI beyond what is authorized by the HIPAA law, but MESSA is not compelled to agree. This form is used to submit the request to MESSA.
A form for members or dependents to use to request alternative confidential communication.
This form is for members to revoke a previously submitted authorization form.
Members can use this form to submit a complaint or request an investigation about a suspected HIPAA (PHI) disclosure.