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    Patient Request For Access To PHI Form

    Uploaded by

    Hermione Granger
    This document contains a patient's request for access to their protected health information (PHI) held by the City of Woodbury. The patient provides their name, contact information, and date of birth. They have the right to inspect or obtain copies of their PHI, including electronically if it is maintained that way. The request describes the specific PHI being requested, how the patient would like it provided (mail, email, transmit to a third party), and is signed and dated by the requestor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Request For Access To PHI Form

    Uploaded by

    Hermione Granger
    37 views2 pages
    This document contains a patient's request for access to their protected health information (PHI) held by the City of Woodbury. The patient provides their name, contact information, and date of birth. They have the right to inspect or obtain copies of their PHI, including electronically if it is maintained that way. The request describes the specific PHI being requested, how the patient would like it provided (mail, email, transmit to a third party), and is signed and dated by the requestor.

    Original Description:

    Patient_Request_for_Access_to_PHI_Form

    Original Title

    Patient_Request_for_Access_to_PHI_Form

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    © © All Rights Reserved

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    This document contains a patient's request for access to their protected health information (PHI) held by the City of Woodbury. The patient provides their name, contact information, and date of birth. They have the right to inspect or obtain copies of their PHI, including electronically if it is maintained that way. The request describes the specific PHI being requested, how the patient would like it provided (mail, email, transmit to a third party), and is signed and dated by the requestor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    37 views2 pages

    Patient Request For Access To PHI Form

    Uploaded by

    Hermione Granger
    This document contains a patient's request for access to their protected health information (PHI) held by the City of Woodbury. The patient provides their name, contact information, and date of birth. They have the right to inspect or obtain copies of their PHI, including electronically if it is maintained that way. The request describes the specific PHI being requested, how the patient would like it provided (mail, email, transmit to a third party), and is signed and dated by the requestor.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Patient Request for Access to Protected Health Information

    Patient Name: _______________________________Phone:_____________________

    Street Address: _________________________________________________________

    City: ___________________________State: ______________ Zip Code: __________

    Email: ________________________________Date of Birth: _______________________

    Right to Request Access to Your PHI and Our Duties:


    You (or your authorized representative) have the right to inspect or obtain a copy of your protected
    health information (“PHI”) that we maintain in a designated record set. If we maintain your PHI in
    electronic format, then you also have a right to obtain a copy of that information electronically. In
    addition, you may request that we transmit a copy of your PHI directly to another person and we will
    honor that request when required by law to do so. Requests to transmit PHI to another party must be in
    writing, signed by you (or your representative), and clearly identify the designated person to whom the
    PHI should be sent, and where the PHI should be sent.

    Generally, we will provide you (or your authorized representative) access to your PHI within thirty (30)
    days of your request. We may verify the identity of any person who requests access to PHI, as well as
    the authority of the person to have access to the PHI by asking the requestor to provide the patient’s
    social security number, date of birth, legal authority to act on behalf of the patient (such as a power of
    attorney) or other information necessary to verify that the requestor has the right to access PHI. In
    limited circumstances, we may deny you access to your PHI, and you may appeal certain types of
    denials. We may also charge you a reasonable cost-based fee for providing you access to your PHI,
    subject to the limits of applicable state law.

    Request for Access to PHI:


    Below, please describe the PHI that you are requesting access to with as much specificity as possible.
    Specify dates of service and other details that will allow the City of Woodbury to accurately and
    completely fulfill your request.

    ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    2100 Radio Drive  Woodbury  Minnesota  55125-9598


    651-714-3600  woodburymn.gov
    Specify How You Would Like us to Provide Access:
    Please check all that apply and fill out the requested information, where indicated.

    ____ Please provide me with a copy of my PHI

    ____ Mail. Please send a copy of my PHI to me at the following address:

    Street: _______________________________________________

    City: ______________________State:______ Zip Code: ________

    Format (paper copy, digital copy on a disc, etc.):


    ______________________________________________________

    ____ Email. Please email a copy of my PHI to the following email address in the
    specified format:

    Email address: _________________________________________

    Format (PDF, Word, etc.):_________________________________

    ____ Please transmit a copy of my PHI to the following party at the following mailing address
    or email address in the specified format:

    Designated Party: _____________________________________________

    Street: ______________________________________________________

    City: _________________________State:_______ Zip Code: __________

    Email address: _______________________________________________

    Format (Paper, PDF, Word, etc.):_________________________________

    ____ I would like to inspect a copy of my PHI (we will arrange a convenient time and place for
    you to inspect a copy of your PHI during normal business hours)

    Signature of Requestor: ______________________________ Request Date: _________

    Requestor Information (if requestor is different from patient):

    Name: ___________________________________

    Relationship to Patient (parent, legal guardian, etc.):____________________________

    Street Address: _________________________________________________________

    City: ___________________________State: ______________ Zip Code: __________

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