hipaa-forms

HIPAA Forms

To improve the quality of our service, you can view and print the forms regarding the protected health information.

Authorization for use and/or disclosure of protected health information (Update: 01-01-22)

Request for access to your protected health information (Update: 07-06-22)

Request for accounting of disclosures(Update: 07-06-22)

Request to amend protected health information (Update: 07-06-22)

Request for Confidential Communications (Update: 03-02-23)

Privacy complaint form (Update: 07-06-22)

Request for the restriction of use and/or disclosure of protected health information (Update: 07-06-22)

Request to revoke my authorization for use and or Disclosure of protected health information (Update: 07-06-22)

Request for termination of a restriction for use and or Disclosure of protected health information (Update: 07-06-22)

MCS Classicare is a product underwritten by MCS Advantage, Inc. MCS Classicare is an HMO plan with a Medicare contract and a contract with the Medicaid program in Puerto Rico. Enrollment in MCS Classicare depends on contract renewal. MCS Advantage, Inc. complies with federal civil rights laws applicable and does not discriminate on grounds of race, color, national origin, age, disability or sex. MCS Advantage, Inc. cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. MCS Advantage, Inc. 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。 This information is not a complete description of benefits. Call 1.866.627.8183 (TTY: 1.866.627.8182) for more information. ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1.866.627.8183 (TTY: 1.866.627.8182). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.866.627.8183 (TTY: 1.866.627.8182). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1.866.627.8183（TTY: 1.866.627.8182). Medicare beneficiaries may also enroll in MCS Classicare through the CMS Medicare Online Enrollment Center located at www.medicare.gov. Every year, Medicare evaluates plans based on a 5-star rating system. Multilingual Interpreting Services. Learn more about our service area listing.