Hipaa Request Authorization Form

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TOPS MARKETS, LLC
[Insert Logo]
HIPAA REQUEST/AUTHORIZATION FORM
This form is to be used by pharmacy customers of Tops Markets, LLC (“Tops” or “we”) who
wish to make any of the following Requests or Authorizations relating to their Protected
Health Information (“PHI”):
-
Authorize Disclosure of PHI
-
Request Restrictions of Disclosure of PHI
-
Request Access to PHI
-
Request an Amendment of PHI
-
Request an Accounting of PHI
-
Request Communications by Alternate Means
-
Agree to the Disclosure of Immunization Records
Please complete the customer information below and sign where indicated, then check the box for
each Request or Authorization you wish to make and complete each applicable section. Once
completed, submit this form to the Tops Privacy Officer by e-mail OR U.S. Mail, at:
OR
Tops Markets, LLC
Attn: Privacy Officer
P.O. Box 1027
Buffalo, NY 14240
Customer Name: ______________________________ Date of Birth: _________________
Address: ____________________________________________________________________*
Phone: _____________________ *
* I authorize Tops Markets, LLC to contact me regarding this form at this address and phone number
_
Customer Signature:
_____________________________________ Date: ___________________
Authorize Disclosure of PHI
I authorize Tops to disclose my PHI to the following individual(s):
Name: _____________________ Address:______________________________ Phone: ______________
Name: _____________________ Address:______________________________ Phone: ______________
NOTE: Tops will only disclose PHI that is directly relevant to the identified individual’s involvement in
your care, and otherwise in accordance with applicable law.

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