Patient Access To Health Information Request For Transfer Of Copy Form

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PATIENT ACCESS TO HEALTH INFORMATION
REQUEST FOR TRANSFER OF COPY
PENINSULA PEDIATRIC MEDICAL GROUP, INC.
50 S. San Mateo Drive #180
1720 El Camino Real #205
San Mateo, CA 94401
Burlingame, CA 94010
(650) 342-4145/ (650) 342-2070 Fax
(650) 259-5050/ (650) 697-1317 Fax
Contact our Practice Privacy Official at (650) 373-1898
As required by the Health Information Portability and Accountability of 1996 and California law, you have a right to
request the opportunity to inspect and copy health information that pertains to you. We will evaluate your request
and will either grant it or explain the reason why the request will not be granted. Your right to access does not
extend to information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action
or proceeding, or to information we received in confidence from someone other that another healthcare provider.
Patient name: __________________________________________ Date of Birth: _______________
Address: ___________________________________________________________________________
Phone number: _________________________
Type of records requested and charges:
 All records (minimum charge-$25; over 60 pages-$40)
 Basic records – copy of immunization record, growth chart(s) & last physical exam only (No charge)
 Retrieve records located off-site ($20 charge; additional copy fees apply if all records needed)
 Other (minimum charge - $25):
____________________________________________________________________________________
Please check one of the following requests:
 Copies for patient or parent to pick-up or mail
 Transfer records to:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City, State &Zip: _____________________________________________________________________
Phone number: _____________________________
__ I hereby agree to pay the charges.
__ Please call me to let me know how much these copies will cost.
__ I am requesting these records be provided without charge to appeal the denial of eligibility for Medi-
Cal, SSDI or SSI/SSP benefits. A copy of the program’s denial notice is attached. I applied for these
benefits on __________________________(date).
PLEASE NOTE: FEES MUST BE PAID WHEN SUBMITTING REQUEST FORM.
Signature: ________________________________
Date: __________________
(
Patient must sign if over 18 years old)
Print name: _______________________________
Telephone: ___________________
Parent
Guardian
Conservator of incompetent patient

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