Medical Records Request

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RE: Request for Copies of Protected Health Information — ________

Dear ________,

I am a patient of your practice and I am writing to exercise my right of access to my protected health information ("PHI") under the Health Insurance Portability and Accountability Act of 1996, the Health Information Technology for Economic and Clinical Health Act, and the implementing regulations at 45 C.F.R. § 164.524. Please provide me with a complete copy of the medical records described in the enclosed authorization.

I am requesting these records for the following purpose: ________.

I request that the records be provided to me in the following form or format, if readily producible: ________. Please deliver the records by the following method: ________.

I understand that, under 45 C.F.R. § 164.524, you are required to act on this request no later than thirty (30) days after receipt, and that any fee charged must be limited to a reasonable, cost-based fee as permitted by that regulation. If there is a charge associated with releasing these records, please submit an itemized billing statement together with the records, and payment will be remitted promptly upon receipt. The amount I have authorized in advance, if any, is $________.

I have enclosed a signed Authorization for Release of Medical Records. If you require any further information from me, you may contact me as follows:

________

Thank you for your prompt attention to this matter.

Sincerely,

_________________________________
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Enclosure: Authorization for Release of Medical Records

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

(HIPAA-Compliant Authorization — 45 C.F.R. §§ 164.508 & 164.524)

§ 1. Patient Information.

Name: ________
Address: ________
Social Security Number: ________
Date of Birth: ________
Telephone: ________
Medical Record/Account No. (if known): ________

§ 2. Authorization for Release.

I, ________ (the "Patient"), hereby authorize the following health care provider (the "Disclosing Party") to release my protected health information:

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to release, disclose, and deliver the medical information described below to the following person or entity (the "Recipient"):

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§ 3. Description of Information to be Released.

I specifically authorize the release of only the following information for the date(s) of service indicated:

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Date(s) of service / treatment period covered: ________

I do not give permission for any other use or redisclosure of this information except as expressly authorized herein.

§ 4. Purpose of the Disclosure.

The information is being released for the following purpose: ________.

§ 5. Specially Protected Information.

Federal and state law afford special protection to certain categories of information. By initialing below, I specifically authorize the release of the following categories of specially protected information to the extent contained in my records (initial each that applies):

_____ Records relating to alcohol or substance use disorder treatment (42 C.F.R. Part 2);
_____ Records relating to mental or behavioral health treatment;
_____ Records relating to HIV/AIDS status or testing;
_____ Records relating to sexually transmitted infections;
_____ Records relating to genetic testing or information.

Patient Initials: ________

§ 6. Redisclosure.

This release does not authorize redisclosure of medical information beyond the limits of this consent. The Recipient is prohibited from using the information for any purpose other than the stated purpose, and from disclosing it to any other party without further written authorization. Where the information includes records protected by 42 C.F.R. Part 2, the following statement shall accompany the disclosure:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 C.F.R. Part 2 and 45 C.F.R. Parts 160 and 164). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2 and 45 C.F.R. Parts 160 and 164. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

I specifically understand and agree that the redisclosure requirements set out above will apply to these records. I further understand that once my information is disclosed to the Recipient, it may no longer be protected by federal or state privacy laws and may be subject to redisclosure by the Recipient.

§ 7. Right to Revoke.

I understand that I have the right to revoke this authorization at any time by submitting a written notice of revocation to the Disclosing Party named in § 2, except to the extent that action has already been taken in reliance upon it. Revocation will not apply to information that has already been released in response to this authorization.

§ 8. Expiration.

This authorization shall remain in effect until the purpose for which the information is to be used has been fulfilled, or until revoked in writing by the Patient. Unless otherwise revoked, this authorization will expire on the following date or event: ________.

§ 9. Acknowledgments.

Xxxxx xx xxxxxxx xxx xxxx xxxxxxxxx xx xxxxxx xxx xxxxxxxx xxxx xx xxxxx xxxxxxx xxx xxxxxx xxxx xxxxxxxxxx xx xxx xxxxxxx xxxxx xxxx xx xxxxxxxx xxx xxxxx xxxxx xx xxxxxxx xxx xxxx xxxxxxxxx xx xxxxxx xxx xxxxxxxx xxxx xx xxxxx xxxxxxx xxx xxxxxx xxxx xxxxxxxxxx xx xxx xxxxxxx xxxxx xxxx xx xxxxxxxx xxx xxxxx xxxxx xx xxxxxxx xxx xxxx xxxxxxxxx xx xxxxxx xxx xxxxxxxx xxxx xx xxxxx.

I authorize the release of information as indicated above.

_________________________________
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Signature of Patient

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Date

§ 10. Personal Representative (if applicable).

Xxxxx xx xxxxxxx xxx xxxx xxxxxxxxx xx xxxxxx xxx xxxxxxxx xxxx xx xxxxx xxxxxxx xxx.

Name of Personal Representative: ________
Relationship / Authority to Act: ________

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Signature of Personal Representative

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Date