Free HIPAA Access Request Form Template
HIPAA Access Request Form
Complete this form to request access to your Protected Health Information.
Name
Date of Birth
Phone Number
Email Address
Information Requested
Check all that apply:
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Medical Records
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Billing Records
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Test Results
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Treatment Notes
Preferred Format
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Paper Copy
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Electronic Copy
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In-Person Review
Purpose of Request
Purpose for accessing the requested information:
Acknowledgment
By signing below, I acknowledge that I am requesting access to my PHI as specified above. I understand this request will be processed in accordance with HIPAA regulations. I may be charged a reasonable fee for the preparation or delivery of the records.
Name:
Date:
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