Get Hughston Patient Request To Inspect And Copy Protected Health Information 2020-2025

Filling out the Hughston Patient Request To Inspect And Copy Protected Health Information form online is a straightforward process designed to facilitate your access to medical records. This guide provides you with clear, step-by-step instructions to ensure you complete the form accurately.

Follow the steps to successfully complete your request.

1. Press the ‘Get Form’ button to access the form and open it in your chosen online editor.
2. Fill out your personal information in the 'Patient Name,' 'Chart Number,' and 'Address' fields. Ensure all details are accurately entered as they appear on your medical records.
3. Enter your 'Date of Birth,' 'City/State/Zip,' 'Home Phone,' and, if applicable, 'Work Phone.' This information helps in identifying and verifying your request.
4. Select the types of medical records you want to request by checking the appropriate boxes, such as 'Office visits' or 'Physical/Occupational Therapy notes.' Include details for any 'Other' records you may need.
5. Specify how you would like to receive the records. You can either have them mailed to your listed address or indicate your preference for pickup along with a contact number for notification.
6. Acknowledge the fees associated with your request by agreeing to the listed costs, including the $5.00 fee for processing and applicable per-page rates as outlined by Georgia state guidelines.
7. Sign and date the form where indicated to validate your request. If you are a legal representative, ensure your signature is clearly marked as such.
8. Save the completed form and download or print it for your records. Once completed, you can submit the form according to the specified instructions, including faxing it back to 706-494-3042.

Take the next step toward accessing your medical records by filling out the form online today.