Patient Request for Access to Protected Health Information

Patient Name (required)

Phone Number (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Email (required)

Date of Birth (required)

Right to Request Access to Your PHI and Our Duties: You (or your authorized representative) have the right to inspect or obtain a copy of your protected health information (“PHI”) that we maintain in a designated record set. If we maintain your PHI in electronic format, then you also have a right to obtain a copy of that information electronically. In addition, you may request that we transmit a copy of your PHI directly to another person and we will honor that request when required by law to do so. Requests to transmit PHI to another party must be in writing, signed by you (or your representative), and clearly identify the designated person to whom the PHI should be sent, and where the PHI should be sent. Generally, we will provide you (or your authorized representative) access to your PHI within thirty (30) days of your request. We may verify the identity of any person who requests access to PHI, as well as the authority of the person to have access to the PHI by asking the requestor to provide the patient’s social security number, date of birth, legal authority to act on behalf of the patient (such as a power of attorney) or other information necessary to verify that the requestor has the right to access PHI. In limited circumstances, we may deny you access to your PHI, and you may appeal certain types of denials. We may also charge you a reasonable cost-based fee for providing you access to your PHI, subject to the limits of applicable state law.

Request for Access to PHI:

Below, please describe the PHI that you are requesting access to with as much specificity as possible. Specify dates of service and other details that will allow Red, White & Blue Fire Protection District to accurately and completely fulfill your request. (required)

Please provide me with a copy of my PHI

If mailed:

Mailing Address

City

State

Zip Code

If emailed:

Third Party Information:

Name

Mailing Address

City

State

Zip Code

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

Date (required)

Printed Name (required)

Relationship to Patient (required)

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