Medical Records Request (Page 3 of 3) in pdf

Process if Request Denied

I understand that USC may deny this request under limited circumstances as provided for under

federal and state law protecting the privacy of health information. I further understand that, except

as otherwise permitted under applicable law, I have the right to have a denial of my request

reviewed by a licensed health care practitioner selected by the USC who did not participate in the

initial decision to deny my request.

I understand that USC will notify me of its decision to approve or deny my request to inspect the

Requested Information within five (5) working days of receiving this request and within fifteen (15)

days after receiving this request if my request is for copies, unless I agree to additional time to

respond. USC will provide me with a summary of the Requested Information within ten (10)

working days of receiving my request, or within a maximum of thirty (30) days if USC notifies me

that more time is necessary, either because of the length of the record or because I was discharged

from the hospital within the ten (10) day period to produce the summary.

Format for Providing Information

I would prefer to:



pick-up or view the Requested Information at a mutually agreeable time and place; OR



have the Requested Information mailed to me at the following address; OR

_____________________________________



have the Requested Information mailed to __________________ at the following address:

_____________________________________

I understand that USC will charge me [$_____] per page for the copying services necessary to

complete my request, as well as any applicable mailing fees.

____________________________________________

__________________

Signature of Patient (or Personal Representative)

Date

____________________________________________

Printed name of Patient or Personal Representative

Date

____________________________________________

Relationship of Personal Representative to Patient

05.03 (rev.)

Medical Records Request Page 3