Medicaid customers, please use the appropriate state form below
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. These rights are collectively known as “Individual Rights."

For more information on HIPAA individual rights, click here.

To exercise your rights under HIPAA, click here.

Release of Information (ROI) / Authorization to Disclose Protected Health Information (PHI). See below for a form you can complete to allow someone else to access your healthcare information or speak on your behalf:

This authorization does not allow anyone but you to make decisions on your behalf. If you want help with your health care and treatment decisions, you must get additional legal documentation.

Standard ROI/Authorization form – English eForm

Standard ROI/Authorization form – Spanish PDF