REQUEST TO ACCESS PROTECTED HEALTH INFORMATION (PHI)
Please print all requested information to prevent delays in our response & provide completed form to your facility.
Patient Name: ____________________________________________________________________________________________________
Maiden or Other Name
Address:_______________________________________City:_____________________ST: _________ Zip:_________
Date of Birth: _______- ________-_______
Type of access requested:
Summary or explanation
View on Site
I request access to: (Please check only one box):
All of my protected health information in my medical records, including mental health, HIV, health status
or substance abuse records.
Protected health information for the dates of: (______________________) to (________________________).
Protected health information about the following condition or injury:________________________________
Other (please describe):_______________________________________________________________________
Please send records
(Name and Address, if mailing)
call at number above to pick up or
mail by USPS to address above
other electronic method
*For security of your records, all emails are sent encrypted.
encrypted email disclaimer:
I understand that records sent through unencrypted email pose a security risk but it is my
requested method of receipt.
SIGNATURE OF INDIVIDUAL
SIGNATURE OF PERSONAL REPRESENTATIVE
RELATIONSHIP TO INDIVIDUAL
FOR INTERNAL USE ONLY
Complete the sections below and retain this request with patient medical records.
Date Request Received:
Notice of Decision is :
Approved and provided per request
Denied for reason indicated below:
Information requested is not a part of patient’s designated record set.
Information requested is not available to the patient for access as required by federal or state law.
A physician has determined that access to information requested may endanger the life or physical safety of the individual or
Physician who reviewed if applicable
Staff member who processed request
Access- GCHJF52EN 08/15