You can use this form when you want to see your own protected health information.
The HIPAA designated record set includes a complete copy of your health information and any enrollment, claims processing, payment, case and medical notes.
What you’ll need:
- Your enrollee ID card
- A printer to print the form
- An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number.
If you have any questions, please contact us.
Request for Access to Designated Protected Health Information Records (PDF)