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Mississippi Envision - Submit Privacy Issue

* Indicates Mandatory Field
Submit Privacy Issue
 This form is for use by Medicaid beneficiaries to report a known or suspected incident of misuse of their protected health care information.
 If you are a beneficiary with a specific issue, please enter the information below and click Submit.
 The information will be sent to a customer service representative.
 Please click Submit only once.
 *Medicaid Beneficiary ID #:    
 *Last Name:  *First Name:
 *Phone Number:  Ext.:
 *Description of Issue: