Get Patient Information - Request For Access To Phi

Navigating the process of requesting access to your personal health information can feel daunting, but it does not need to be. This guide will provide you with clear, step-by-step instructions to help you complete the Patient Information - Request For Access To PHI form online with confidence.

Follow the steps to successfully fill out the form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering your full name in the 'Patient name' field, followed by your date of birth. Ensure that the date format is clear.
3. Provide your address, including street address, city, state, and zip code, to ensure clear identification.
4. Enter your telephone number in the designated field for easy contact.
5. If applicable, include your medical record number for office use. This can help expedite the request.
6. Specify the date(s) of treatment for which you are requesting information. This information will help narrow down the records pertinent to your request.
7. In the 'Requested Information' section, select the appropriate types of records you wish to access. You may choose one or multiple options from the list provided.
8. If your request includes sensitive information, ensure you mark that you understand this may involve specific records, such as those related to AIDS, HIV infection, or behavioral health.
9. Identify who will receive the records by completing the name, address, and phone fields for the designated recipient.
10. Choose your preferred method of receiving the records by selecting one of the options available (printed copy, CD, or electronic download). If choosing electronic, clearly print the email address.
11. Sign the form in the designated area, ensuring that all applicable signatures are completed, including the signature of a healthcare agent if needed.
12. Finally, review the completed form for accuracy. After confirming all information is correct, save changes, and download or print the form as needed for submission.

Begin filling out your Patient Information - Request For Access To PHI form online today.