This notice describes how medical information about you may be used and disclosed
and how you can gain access to this information. Please review it carefully.
Purpose of request - I request and authorize the disclosure or release of my protected health information
This form is provided so that we may address your concerns with the privacy policies and procedures of our
Under the Privacy Rule, a patient or their personal representative may request access to the patient’s
protected health information for the purposes of inspection and/or obtaining a copy of the protected health
Requesting a restriction on the use and/or disclosure of my protected health information.
Requesting an amendment to my protected health information maintained by Mid-Michigan
Requesting a list of disclosures of my protected health information during a specific date
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
Please be advised that due to the many hundreds of insurance plans available
and the frequent plan changes, we cannot be informed regarding
the covered benefits of each patient.
What you should know about scheduling your preventive care appointment.
Patient Centered Medical Home
MMP Compliance Program and Reporting