Request for Records & Data

Health Information Data Requests

To request data regarding Medicaid programs, please complete the following forms:
FileTypeSizeUploaded onDownload
Data Request FormDOCX112.58 KB13 Dec, 2019 Download
Data Request FormPDF281.65 KB12 Dec, 2019 Download
Medical Representative AuthorizationPDF130.35 KB17 Nov, 2016 Download
KC6100MedicalRepresentativeAuthorizationForm_SPPDF494.06 KB05 Jan, 2017 Download
Facilitator Authorization FormPDF164.14 KB17 Nov, 2016 Download
KC6200FacilitatorAuthorizationForm_SPPDF494.81 KB05 Jan, 2017 Download

Protected Health Information (HIPAA)

If you are requesting information about a specific consumer, please have the individual complete and sign the authorization form below.
FileTypeSizeUploaded onDownload
Autorización para la Divulgación de Información de Salud ProtegidaPDF84.10 KB17 Nov, 2016 Download
Personal Health Information Release Authorization 9-12-17PDF728.70 KB12 Sep, 2017 Download