Patient Access To The Medical Record Request Form printable pdf download

Patient Access To The Medical Record Request Form

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Patient Access to the Medical Record Request Form

,request access to my child's medical

records for my personal inspection or by

,my personal

representative. (Please request date and time requested for record access)

, request Red Rock Pediatrics

make copies of my child's medical records for my personal inspection. I understand that

these records contain protected health information (PHI). I agree to be responsible for the

cost of copying these records, including copying fees, labor, supplies, and postage (if

applicable). The charge for this will be $ _ per page and I will be charged a minimum

I agree to pay for this prior to the service being rendered.

Patient! Guardian Signature

Patient Printed Name and Date of Birth

Date of request

Practice Response to Request (Must be within 60 days of receipt of request.)

__ Grants all or part of your

__ Denies all or part of your request ___________________________

For the following reason: (Circle all that apply)

Not part of your designated record set; contains psychotherapy notes; information was

compiled for civil, criminal or administrative actions; subject to CLlA; regards inmate at

correctional institution; was created during research; is subject to Federal privacy act;

was not created by this practice.

Patient may not appeal if denial is for any of the above reasons

Denied at the discretion of the practice as the information may be harmful to the

patient or a third party

Requests a 30-day extension to respond due to ______________________

Patient Access To The Medical Record Request Form