PCF2010.0_Request Access, Copy, Amend Or Correction Of Health Information

REQUEST ACCESS, COPY, AMEND OR CORRECTION OF HEALTH INFORMATION

SECTION A: Client to complete the following information.

Date:

Phone Number:

Name:

Date of Birth:

Address:

REQUEST I hereby request that HDC provide me with (check all that apply):

¨	My case records.
¨	My billing records.
¨	Any other personally identifiable information used by __________________.
	Please describe:__________________________________________________________
¨	I am interested in access to or obtaining a copy of all requested information maintained by HDC.
¨	I am interested in accessing or obtaining a copy of the requested information relating to the following time period:_______________through _______________.
	I would prefer to receive the requested information in the form of a summary prepared by ________ at a cost to me of $________.
I wish to receive the requested information in the following format:
¨	Photocopies
¨	Electronic transmission (if available)
¨	Other (if available)

Signature of individual or personal representative
Printed name of legal representative				Date
Relationship to individual

SECTION B: HDC Privacy Officer to complete the following.

Request for access or copy is

¨ Accepted ¨ Denied

If denied, check the following reason for denial:

¨	Protected health information is not part of the individual's designated record set.
¨	Federal law forbids making the requested information available to the individual for inspection (eg CLIA or Privacy Act of 1974)
¨	The requested information is psychotherapy notes.
¨	The requested information has been compiled for legal proceeding.
¨	The requested information was obtained under promise of confidentiality and access would be reasonably likely to reveal the source of the information.
¨	The requested information is temporarily unavailable because the individual is a research participant.
¨	Licensed health care provider has determined that access to the requested information would result in physical harm to the individual or others.
¨	Licensed health care provider has determined that the requested informationidentifies a third person who may be physically, emotionally, or psychological harmed if access to the information is granted.
¨	We are acting under the direction of a correctional institution and letting the inmate access or obtain a copy of the requested information would jeopardize the health, safety, security, custody, or rehabilitation of another person at the corrections institution.
¨	The requested information is not maintained by our facility.

RIGHT TO REVIEW:

You ¨ do ¨ do not have the right to a review of this denial.

I request permission to correct or amend my PHI in the following way:

REQUEST FOR AMENDMENT OR CORRECTION:

¨ Accepted ¨ Denied

¨ You do have a right to complain to the Secretary of the Department of Health and Human Services.

Signature of staff person			Date
Print name and title