DHHS Medicaid MMIS External Access Confidentiality Statement 2026

1. Click ‘Get Form’ to open the DHHS Medicaid MMIS External Access Confidentiality Statement in the editor.
2. Begin by filling out the 'Employee Information' section. Clearly print your name, title/position, work phone, and email address. Ensure all information is accurate for proper identification.
3. In the 'Immediate Supervisor Information' section, provide your supervisor's printed name, position title, work phone, and email. This establishes a point of contact for any necessary approvals.
4. Complete the 'Contact Person Information' by entering the contact person's name as stated on the confidentiality agreement along with their phone number and email address.
5. Indicate if you are requesting external access to claim status for specific Group NPI numbers. Answer questions regarding renewing an existing user ID or replacing staff as applicable.
6. Review all entries for accuracy before signing at the bottom of the form. Your signature confirms your understanding of confidentiality obligations.

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