Follow the steps to complete your request accurately.

1. Press the ‘Get Form’ button to access the MI MiHIN Participation Change Request form and open it in your editor.
2. Choose whether you want to opt out of allowing electronic access to your health information by selecting the appropriate box on the form. If you wish to reverse a previous opt-out decision, select that option instead.
3. Fill in all required personal information, including first name, middle name, last name, previous last name (if applicable), date of birth, and gender. Ensure all fields are completed accurately.
4. Enter your current street address, city, state, and zip code in the designated fields to confirm your location.
5. Provide your telephone number and, if desired, a cell or alternate phone number in the appropriate sections.
6. If you are signing on behalf of the patient as a legal representative, include your name and relationship to the patient in the specified areas.
7. Sign and date the form as either the patient or legal representative. If the patient is under 18, a parent or legal guardian's signature is required.
8. Complete the health care provider section by providing the name, phone number, address, and fax number of the provider assisting with this request.
9. Ensure all information is accurate and complete before submitting the form. This includes verifying the fax number for submission to GLHC.
10. Once you have filled out the form, you may choose to save your changes, download, print, or share the document as needed.

Complete your MI MiHIN Participation Change Request online today to manage your health information access preferences.