Privacy Forms

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed by entities covered under the HIPAA privacy rules.

Authorization to Use and Disclose Protected Health Information (PHI)

Members should use this form to provide MESSA with written authorization to use, discuss or disclose their PHI with a third party.

Authorization to Use or Disclose Psychotherapy Notes

Similar to the written authorization form, this form is required for specific authorization to use or disclose psychotherapy notes to MESSA or from MESSA.

Protected Health Information (PHI) Disclosure Accounting Request

Members should use this form to request a summary of disclosures (with a six year maximum) by MESSA of their PHI.

Request to Amend Protected Health Information (PHI)

This form is for members to request an amendment to the PHI MESSA maintains.

Request to Inspect or Obtain Designated Records Containing Your PHI

This form is for members to request a review of the records MESSA maintains containing their PHI.

Request to Restrict MESSA's Use or Disclosure of Protected Health Information (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.

Request to Use Alternative Means or an Alternative Location for Confidential Communication

A form for members or dependents to use to request alternative confidential communication.

Revocation of Authorization to Use and Disclose PHI

This form is for members to revoke a previously submitted authorization form.

Privacy Policy and Procedures Complaint Form

Members can use this form to submit a complaint or request an investigation about a suspected HIPAA (PHI) disclosure.

1475 Kendale Blvd., P.O. Box 2560, East Lansing, MI 48826