Hipaa Request Authorization Form (Page 3 of 4) in pdf

TOPS MARKETS, LLC

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Request an Amendment of PHI

I request the following amendment to my PHI (Please describe the amendment request in detail, and

the reason for the request. You may attach additional sheets to this form if necessary. Please also attach

any backup documentation you may have to support your request):

_____________________________________________________________________________________

NOTE: Tops may deny your request for amendment in accordance with our Notice of Privacy Practices. If

we deny your request for amendment, we will give you a written denial including the reasons for the

denial and you will have the right to submit a written statement disagreeing with the denial.

Request an Accounting of PHI

I request an “accounting” of disclosures of my PHI. I understand that this is a listing of disclosures made

by the Pharmacy or by others on my behalf, but does not include disclosures for treatment, payment

and health care operations, disclosure made pursuant to my Authorization, and certain other

exceptions.

Please complete the following:

Accounting time period (must be within six years of the date of this request):

From:_________ To:__________

Location(s) of all Tops pharmacies for which I am requesting an accounting:

______________________________________________________________________________

NOTE: The first accounting provided by Tops within a 12-month period will be free; for further requests,

we may charge you our costs. We will notify you of our costs and you may choose to withdraw or modify

your request at that time.

Hipaa Request Authorization Form Page 3