Authorization For Patient To Access Their Medical Record Form

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RIVERSIDE COUNTY REGIONAL MEDICAL CENTER
AUTHORIZATION FOR PATIENT TO ACCESS THEIR MEDICAL RECORD
It is my understanding that I have the legal right, with certain limitations, to either view or obtain copies of
my protected health information, or that of my unemancipated minor child whose treatment I authorized.
This right is also granted to the guardian of a minor child, conservator of the person, psychiatric or non-
psychiatric. Further, I understand that when deemed advisable by a physician, this right may be denied
per the law. In such an event, I will be advised of my options.
I understand there is a charge for obtaining copies of the medical record. The charge is 25 cents per page
if photocopied or 50 cents per page if printed from microfilm.
Printed Patient Name_________________________________________________________________
Medical Record #____________________________ Phone # _________________________________
Date of Birth____________________________ Social Security # _____________________________
Address____________________________________________________________________________
I hereby request that Riverside County Regional Medical Center provide access to the medical record of
the patient named above. Ph # (951) 486-5040 Fax # (951) 486-5075
I request this access as the: (check one)
Form of Delivery:
Patient
Mail
Parent of the minor patient
Pick-Up
Guardian of the minor patient*
Call and leave information on phone
messaging device or family member
Conservator of the person, psychiatric*
Conservator of the person*
* Requires written legal proof of guardianship or conservatorship
The type of access requested is: (check one)
Dates of treatment from __________________________ to _________________________________
Inspection of the record
Copies of the record
I request access to:
Mental Health records from ETS/Inpatient Treatment Facility
Entire medical record
The following sections of the record only: (be specific as possible)
Signature_____________________________________________Date/Time: ______________________
Printed Name_________________________________________________________________________
Rev. 3/12

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