North Dakota Olmstead Inquiry
Privacy Notice
This notice describes how private information about you may be used and disclosed.

You have privacy rights through the North Dakota Health Information Network (NDHIN) and the federal Health Insurance Portability and Accountability Act (HIPAA). These laws protect your privacy, but also let us give information about you to others if the law requires it. 

Why do we ask for this information?
The information you provide on this form helps us know who we are contacting and why you need our help. The information you provide is used to track data, so we can monitor trends in information we receive. 

Do you have to answer the questions in this form?
You do not have to give us the information we request in this form, but without it we may not be able to reach you, or to help with your concern.
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Name *
Email *
Phone Number
Can we leave a voicemail at this phone number? *
Topic you'd like help with (choose one) *
Brief description of your concern *
Who else have you contacted about your concern?  *
(i.e. case manager, lead agency/tribe, provider, Ombudsman, etc.)
Consent Statement *
I understand that by submitting this form, my information may be shared with the appropriate state agency or others involved in my services, including employees of state, county, tribal, local, and federal agencies, managed care organizations and other agencies to help answer my question or resolve my issue. Only the minimum information necessary to help will be provided. 
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