Request for Access to Medical/Dental Records Request for Access to Medical or Dental Records Our notice of Privacy provides information about our use of a patient’s protected health information. The Notice contains a Patient Rights section describing your rights under the law. Patients have the right to access, inspect, and copy protected health care information used to make decisions about them. The Practice will only include information used to make decisions about the patient. The Practice may limit access to information generated only by this Practice. Under some circumstances, such as increased risk of harm or injury, the Practice may withhold the requested information. The Privacy Officer of this Practice will evaluate the Request and notify the patient of our decision within fifteen (15) days of this Request. If the Request is approved, the Practice will provide the information within thirty (30) days, or within sixty (60) days if such extension is necessary. Reasonable costs will be charged for the Request. Costs will be submitted to the patient upon approval of the Request. The Practice may provide a summary of the requested information if you are agreeable. The Practice provides this form to comply with the Health Portability and Accountability Act of 1996 (HIPPA) Name * Name First First Last Last Email * Heath Care Information requested. Please provide dates, diagnosis, treatment, or any other indications of the specific information you desire: * Is the summary of the information acceptable? * Yes No Do you wish to * Arrange an appointment to inspect the requested information? Receive a copy of the information? Neither Instructions regarding copies * I will pick the copies up Please mail the copies to me at the following address Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal This request is signed by signature keyboard Clear Patient name or patient representative Date * Captcha Submit If you are human, leave this field blank.
