Patient Request For Access To Health Information Form

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TULANE UNIVERSITY MEDICAL GROUP
PATIENT REQUEST FOR ACCESS TO
HEALTH INFORMATION
Our patients and their personal or legal representatives have the right to inspect and obtain a copy of most
information in our records that may be used to make decisions about the patients or their treatment for as long as we
maintain the information in our records. Patients and their personal or legal representatives may also request that
we provide a summary of the information (instead of copies) or an explanation of complicated information. Please
see our Notice of Privacy Practices for a more detailed description of these rights and the process we follow once we
have received a request. To request access to records, please complete and return the following request form.
PATIENT INFORMATION
Patient Name: _______________________________________________________________
Last
First
MI
Telephone: __________________________(daytime) ______________________________ (evening)
_________________________________________
Address:
_________________________________________
_________________________________________
Email Address (optional): ___________________________________
ACCESS REQUESTED
Please answer the following questions. You may attach a separate page if more space is needed.
What information would you like to access? If you can, please provide the dates that tests were performed or
treatment was provided.
What type of access are you requesting? Check all that apply:
INSPECT _____ COPY _____ SUMMARY _____ EXPLANATION ______
If your request to inspect the information is granted, we will provide you with further information on how to
schedule an appointment with our staff to inspect your records.
If you are requesting a copy, summary, or explanation of the information, how would you like these materials
delivered to you? You may pick up these materials at our facility or request that we send them to you by
regular mail.
Check one: PICK UP _____ BY MAIL _____

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