Request for Access to Protected Health Information By Individual Patients

Request for Access to Protected Health Information By Individual Patients
Individual Patient Name*
Patient Date of Birth*

MonthDayYear
Date
Patient Phone Number (Home/Cell)*
Please enter a valid phone number.Format: (000) 000-0000.
Release Information ToReceive Information From
Name of Individual/Institution*
Who are we releasing information to or receiving information from?
Paper copyFaxElectronic copyVerbal communication only
Mailing Address of Individual/Institution Receiving Records

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Individual Receiving Records*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number of Individual Receiving Records
Please enter a valid phone number.Format: (000) 000-0000.
Email Address of Individual Receiving Records*
example@example.com
*Email is not a secure means of communication. We will encrypt email communications of your records unless you tell us you prefer us to use unencrypted email. If you prefer we not encrypt our communications, please initial here Initials
Specific DatesAll Dates
Specific Dates:
Date* through Date*
Intake ReportTermination SummaryNeuropsychological report with summary of scoresNeuropsychological report without summary of scoresVerbal communication (no records released unless otherwise specified)Other
PermittedProhibited
Signature of Patient or Authorized Representative*

Clear
Date*

MonthDayYear
Date
Printed Name of Patient or Authorized Representative*
Relationship to Individual Patient
Should be Empty: