Request for Access Request for Access to Protected Health Information Under the Privacy Rule, you or your designated personal representative have the right to access your protected health information (PHI) for the purposes of inspection and/or obtaining a copy. There are certain conditions under which we are permitted to deny access to your PHI. If relevant, any conditions of denial will be explained to you. PDF VersionInspection Inspection - Access to inspect PHI is provided on a scheduled basis. Please note that, due to privacy and risk management guidelines, original documents of PHI may only be inspected in the presence of one of our staff members and original materials may not be removed from the facility. Our receptionist can provide scheduling information for you at the time of your request. Copies - If you prefer to receive copies of your protected health information, we may charge a reasonable, cost-based fee. If a copy fee applies, the amount will be communicated to you at the time of your request. Release to Third Party - If you wish to release a copy of your records to a third party, please complete the following: Who will be authorized to receive information (list the individual/entity who is to receive your PHI):Individual/Entity Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxEmail * Secure Communication - Note that regular email is not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate email as your preferred method of disclosure if this is of concern to you. Description of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above:Entire patient record Entire patient record Only share the following: Only Share If applicable, please specify the format in which you would like copies of PHI provided to you, or your designated recipient. We will accommodate your request, if possible.Format Paper Copy Electronic Copy Preferred Format Patient Name (Printed)* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient Signature* To sign, please preface your signature with "/s/" to confirm you're signing electronically.Date* MM slash DD slash YYYY
