Healthcare Access Request

Healthcare Access Request

Patient Information

Patient Name:

Insurance Information

Medical History (for identification)

Access Requested

I request access to the following medical information (check all that apply):

Entire medical record    Progress notes    Imaging reports    Laboratory results

Clinical summaries    Billing records    Other:

From:    To:

Purpose of Request

Continuing care    Personal use    Legal    Insurance claim

Employment/school    Other:

Authorized Recipient(s) / Accessors

Method of Access / Delivery

Electronic portal access    Paper copy    Secure email    Pick up in person

Fax:    Other:

Sensitive Information

I specifically authorize release of the following sensitive records if checked below (if not checked, these will be excluded):

Mental health / psychotherapy notes    HIV/AIDS-related records    Substance abuse treatment records

Genetic testing information    Reproductive health / pregnancy records

Fees and Processing

I understand that fees for copying and mailing or other processing costs may apply and will be charged in accordance with the provider's fee schedule. The provider will ordinarily respond to this request within 30 days; in limited situations an extension of up to 30 additional days may be required and will be communicated in writing.

Acknowledgement of potential fees: I acknowledge I may be charged fees for copies or delivery.

Revocation and Expiration

This authorization is voluntary. I may revoke this authorization at any time by providing written notice to the health information management department, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

HIPAA Acknowledgment

By checking the box below I acknowledge that I have been offered or received the provider's Notice of Privacy Practices and understand how my protected health information may be used or disclosed in processing this request.

I acknowledge receipt of the Notice of Privacy Practices.

Certification and Authorization

I certify that I am the patient or am authorized to act on behalf of the patient. I authorize the release of my protected health information as described in this form. I understand that once information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I release the provider and its agents from any legal responsibility or liability that may arise from the release or disclosure of the information authorized herein, to the extent permitted by law.

Identity Verification

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