Form Hipaa 205p - Statement Of Disagreement For Denial Of Access To Health Information - Health Insurance Portability And Accountability Act
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1S
D
D
TATEMENT OF
ISAGREEMENT FOR
ENIAL OF
A
H
I
CCESS TO
EALTH
NFORMATION
Name:
Date:
Mailing Address:
Date of Birth:
City/State/Zip:
Medicaid ID# or Soc. Sec.#:
I disagree with the decision to deny my request to access my protected health
information because:
Signature of Individual or Personal Representative Authorized by Law:
Date
Signature of Witness (If signed with an “X’ or mark):
Date
Return this form to:
LDH USE ONLY
Date received:
Rebuttal
No Rebuttal
____________________________
Comments:
______________________________________________
______________________
Signature & Title of Agency Representative
Date
HIPAA 205P
Page 1 of 1
Issued 4/14/03
Revised 09/11/2013
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Parent category: Medical