Patient Request For Access To Health Information Form (Page 2 of 2) in pdf

Patient Request For Access To Health Information Form Page 2

If your request is being made because of an emergency, please describe the nature of the emergency and the

date you need the information. We cannot guarantee that we will meet your deadline, but we will do our very

best to accommodate reasonable requests.

FEES

Copying and Distribution Costs. We will charge you a reasonable fee to recover the costs of copying. Our standard

fee for copying is $.25 per page or $5.00 for items we can’t reproduce with a photocopier (e.g., x-rays,

mammograms) and a $10.00 handling fee.

Summary or Explanation. We will also charge a fee to recover the costs of providing any summary or explanations

that you have requested.

A fee of $25.00 will be charged to prepare a summary of the information for you.

A fee of $25.00 will be charged to prepare an explanation of the information for you.

Expedited Requests. We will charge a $25.00 fee to recover the cost of providing an expedited request of your

records.

UNDERSTANDING AND SIGNATURE

By signing below, I am requesting that Tulane University Medical Group provide me with access to health

information in the manner described above. I understand that I will be expected to pay the fees for a summary or

explanation or an expedited request.

Send Completed Form to:

Signature of Patient or Personal Representative

Print Name of Patient or Personal Representative

Date

Description of Personal Representative’s Authority

For Internal Use Only:

Date Received: (MO/DY/YR) ____/____/____

Disposition of Request: ____ GRANTED ____ DENIED ____ PARTIALLY DENIED

Patient Notified In Writing Of Response To Request On This Date: (MO/DY/YR) ____/____/____

Fee Charged For Fulfilling This Request (if applicable): $ _____________

Name or Initials of the manager of the specific site who is processing this request:

____________________________________________________________

Patient Request For Access To Health Information Form Page 2