Medical Records Request Form printable pdf download

BAKERS Counseling Services, LLC

MEDICAL RECORDS REQUEST FORM

Middle

Last

First

Client's Name:

Home Address:

Date of Birth:

Home Telephone:

I hereby request that BAKERS Counseling Services, LLC (BCS) provide me with [please check all

boxes that apply]

a copy of the “ Requested Information” checked below:

My entire medical records (ICA, Treatment Plan, Progress Report, and etc).

Any other personally identifiable information used by BCS

to make medical

decisions about me (Prior Authorization, Sign-In Sheet, and etc).

Please check one of the following boxes:

I am only interested in accessing or obtaining a copy of Requested

Information relating to the time period ________ through ___________.

I am interested in accessing or obtaining a copy of all Requested Information

maintained by BCS.

I understand that any information provided to me pursuant to this request will not

include (i) information compiled in reasonable anticipation of (or for use in) a civil,

criminal or administrative proceeding or as may otherwise be required by applicable law,

or (ii) if I am a parent or legal guardian requesting access to a minor’ s information,

records related to certain categories of treatment as required by law (for example, a

minor’ s treatment for venereal disease, the performance of an abortion operation, or care

and treatment to which the minor is permitted to consent--without needing to obtain

his/her parent’ s/guardian’ s consent first--and has so consented, for example, HIV testing,

STD diagnosis and treatment, chemical dependence treatment, prenatal care, care

received by a married minor, and contraception and/or family planning services).

I understand that BCS may deny this request under limited circumstances permitted

by federal regulations governing the protection of personally identifiable health information. I

further understand that, except as otherwise permitted under applicable federal law, I

have the right to have a denial of my request reviewed by a licensed health

care practitioner selected by BCS who did not participate in BCS’ s decision to deny my

request.

Medical Records Request Form