Request to Patient Access for Health Information Form

Request for Patient Access to Health Information

Medical Records Department

***Please Mail or Fax the Request form to your Respective Practice Location.***

As required by the Health Insurance Portability and Accountability Act of 1996 and state law, you have a right to request the opportunity to inspect and copy health information that pertains to you. We will evaluate your request and will either grant it or explain the reason why the request will not be granted.

I hereby request access to health information for:

Name:

Address:

Date of Birth:

I would like access to: ◻ All the records or ◻ the portion of the records concerning:

(Specify type of disease, accident, dates of treatment, or other portion of records you are interested in.)

Type of Access Requested:

◻ Inspection. Please let me know when I may come to inspect the records. I understand that an employee of this medical practice must be present during the inspection and that I may not make any marks or alter the records in any way.

◻ Copies. I would like copies of the information requested. I understand that I may be charged a fee for the copies as explained below. Please mail the records to:

Name:

Address: _______________________________________
Fax: ________________(if appropriate)

____________________________________________________

Charges – Copies. I understand that you may charge me a reasonable fee of up to $0.65 per page, including any research fees and handling fees, if applicable, for copies of the information requested. I also understand that I may be charged a fee as necessary to cover the cost of materials for providing a copy of an x-ray or photographs.

◻ I hereby agree to pay the copying charges specified above.

◻ Please call me to let me know how much these copies will cost and to arrange payment. ◻ I am requesting these records be provided without charge because they are requested for purposes relating to a claim or appeal under a provision of the Social Security Act. Documentation of the claim or appeal is attached.

Signed: _______________________________ Date: _________________________

Print Name: ____________________________ Telephone: ________________________

If not signed by the patient, please indicate your relationship to the patient __________________