Get Request For Access To Medical Information Form - Palo Alto Medical ... - Pamf

Filling out the Request For Access To Medical Information Form is an important step in gaining access to your or a loved one's medical records. This guide will provide clear instructions on how to complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the designated platform.
2. Affix the patient label in the designated space, and send the form to Health Information Management at M/S 31-306.
3. Complete the patient's details, including their name, medical record number (MRN), primary physician, date of birth, address, daytime phone number, and evening phone number.
4. Indicate the name of the person to be granted access to the medical record and their relationship to the patient. Choose from options such as self, spouse/friend, adult child, parent, guardian, or conservator.
5. If applicable, please furnish a copy of your conservator or guardianship papers with the request.
6. Select the type of access requested by checking all relevant options: view protected health information, ask questions of the physician, make appointments, make medical care decisions, or address billing/insurance issues.
7. Confirm the data authorized for release by checking 'Yes' or 'No' and initialing appropriately for drug/alcohol information and mental health information.
8. Sign the form, print your name, indicate your relationship to the patient, and date the request.
9. If you are a PAMF employee, route your request through your supervisor, who will send it to the HIPAA privacy officer.
10. After completing the form, save changes, download, print, or share it as needed.

Start filling out your Request For Access To Medical Information Form online today.