HIPAA Access Form

HIPAA Protected Health Information Access Form

I understand that state and federal laws permit Family Circle of Care to share information about me, including information regarding the health care services I received (my Protected Health Information), with my family and friends who are involved in my care, or the payment of my health care services. I further understand that I have: (i) the right to grant certain persons access to my Protected Health Information; and (ii) the opportunity to restrict access to my Protected Health Information from certain individuals who might otherwise have access. I understand that granting access DOES NOT give the person access to copies of my medical records.

If you would like to request your medical records (e.g., copies of immunization records, lab results, and physicals), please complete an authorization to release protected health information form.

ACCESS: I would like the following person(s) to have access to my Protected Health Information

Name

Relationship to Patient

Date of Birth

Name

Relationship to Patient

Date of Birth

Name

Relationship to Patient

Date of Birth

Name

Relationship to Patient

Date of Birth

Name

Relationship to Patient

Date of Birth

I understand that I may change or revoke this form at any time by contacting the Health Information Management Department at Family Circle of Care. I understand that such changes or revocation will not be effective for disclosures that may have already been made or access which has already occurred based on this form.

You may leave confidential clinical information on my answering machine/voicemail.

Signature of Patient / Responsible Party

Name of Responsible Party

Date

Cancel

Media

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