Request To Access Protected Health Information (Phi) Form
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1REQUEST TO ACCESS PROTECTED HEALTH INFORMATION (PHI)
Please print all requested information to prevent delays in our response & provide completed form to your facility.
Patient Name: ____________________________________________________________________________________________________
Last
First
MI
Maiden or Other Name
Address:_______________________________________City:_____________________ST: _________ Zip:_________
Date of Birth: _______- ________-_______
Phone #:_________________________________________
M
D
Y
Type of access requested:
Actual Copy
Summary or explanation
View on Site
I request access to: (Please check only one box):
All of my protected health information in my medical records, including mental health, HIV, health status
or substance abuse records.
Protected health information for the dates of: (______________________) to (________________________).
Protected health information about the following condition or injury:________________________________
Other (please describe):_______________________________________________________________________
Please send records
To me
To:
OR
___
(Name and Address, if mailing)
:
Method
Paper Copy
call at number above to pick up or
mail by USPS to address above
*
Email
or
other electronic method
*For security of your records, all emails are sent encrypted.
Un
encrypted email disclaimer:
I understand that records sent through unencrypted email pose a security risk but it is my
requested method of receipt.
(Please initial)
_____________________________________________________ _____________________
______________________________________________________
SIGNATURE OF INDIVIDUAL
DATE
SIGNATURE OF PERSONAL REPRESENTATIVE
DATE
RELATIONSHIP TO INDIVIDUAL
FOR INTERNAL USE ONLY
Complete the sections below and retain this request with patient medical records.
Date Request Received:
mail
in person
email
fax
Notice of Decision is :
Approved and provided per request
Denied for reason indicated below:
Information requested is not a part of patient’s designated record set.
Information requested is not available to the patient for access as required by federal or state law.
A physician has determined that access to information requested may endanger the life or physical safety of the individual or
another person.
Other:
Physician who reviewed if applicable
Title
Phone
Date completed
Staff member who processed request
Title
Phone
Date completed
Access- GCHJF52EN 08/15
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