Hipaa Request Authorization Form (Page 2 of 4) in pdf

TOPS MARKETS, LLC

[Insert Logo]

Request Restrictions on Disclosure of PHI

(please check each that applies)

___ I request that my PHI not be disclosed to my family members, close friends or others involved in my

care.

___ I request that my PHI not be used or disclosed for treatment, payment or health care operations.

___ I request that my PHI not be disclosed to my health insurance company for payment or health care

operations purposes. I understand that Tops is required to agree to this restriction only to the extent the

PHI relates to a health care item or service I receive that is paid for in full by someone other than my

health plan.

Please provide detail on the specific PHI you wish to be subject to the restriction. Tops cannot agree to a

blanket restriction, and will require a new request prior to each provision of services or items:

_____________________________________________________________________________________

NOTE: Tops is not required to agree to your request, except as stated above. If we do agree to your

requested restriction, we will comply with your request except as needed to provide you with

emergency treatment or in accordance with federal and state law. We may terminate your requested

restriction if you agree to the termination orally or in writing. We may also terminate certain restrictions

upon notice to you, except that such termination will only be effective for PHI created or received after

we have notified you.

Request Access to PHI

I would like to inspect or obtain a copy of my PHI (please explain your request):

___ I would like to inspect my PHI (Tops will contact you to arrange for inspection)

___ I would like to obtain a copy of my PHI (Please describe the form and format in which you

would like the PHI to be delivered. For instance, indicate if you would like the information delivered by

e-mail or U.S. Mail, any particular format you request, and your e-mail or mailing address. If a copy is to

be sent to another individual, please include his/her name. Attach additional pages if needed):

_____________________________________________________________________________________

NOTE: Tops may deny your request in certain circumstances. If required by law, we will provide you with

a written explanation and you may have an opportunity to request a review of the denial. If Tops

complies with your request, we may contact you to arrange for alternative methods or formats of

delivery, as permitted by law. We may charge you a reasonable fee for the costs of preparing, copying

and mailing the requested information.

Hipaa Request Authorization Form Page 2