HIPAA PHI Forms
The Health Insurance Portability and Accountability Act (HIPAA) ensures your access to various health and human services, and it protects the privacy and security of your medical records and information. As a health plan, CountyCare regularly communicates with your provider about your care, and we follow strict guidelines outlined by HIPAA.
The forms below can help you:
- Give CountyCare permission to discuss or disclose personal and health information or to share information/documents for a specific purpose (Authorization to Disclose Protected Health Information (PHI))
- Stop CountyCare from discussing or disclosing your personal health information with a previously authorized individual or group Revocation of Authorization to Disclose Protected Health Information (PHI))
- Request an accounting of when CountyCare discloses your personal health information for reasons other than for Treatment, Payment, or Healthcare Operations, or for disclosures made with your authorization or permission (Request for Accounting of Protected Health Information (PHI) Disclosures)
- Request an amendment to your health information maintained by CountyCare or entities on behalf of CountyCare (Request to Amend Protected Health Information (PHI))
- Request that CountyCare restrict disclosures of your health information or request CountyCare provide your protected health information (PHI) by alternative means or at alternative locations (Protected Health Information (PHI) Communication Request)
Download the forms below to make a request regarding your medical records. Questions? Call us at 312-864-8200 / 711 TTD/TTY.