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Patient Request Forms

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Patient Request Forms

As a patient, you have the following rights granted to you under HIPAA:

Ask to see and get a copy of your health records

You can ask to see and get a copy of your medical record and other health information. You may not be able to get all of your information in a few special cases. For example, if your doctor decides something in your file might endanger you or someone else, the doctor may not have to give this information to you.

In most cases, your copies must be given to you within 15 days, but this can be extended to 21 days if you are given a reason. You may have to pay for the cost of copying and mailing if you request copies and mailing.

If you do not need every page of your record, we will provide the following at no charge.  All dictations (Discharge, Summary, Emergency Room Report, Office Visits, History & Physical, Consults and Operative Reports) and all diagnostic studies/results.

Click here for more information about obtaining your personal health information

Have corrections added to your health information

You can ask to change any wrong information in your file or add information to your file if it is incomplete. For example, if you and your provider agree that your file has the wrong result for a test, the provider must change it. Even if the provider believes the test result is correct, you still have the right to have your disagreement noted in your file.

In most cases the file should be changed within 10 days, but can be extended to 21 days if you are given a reason.

PDF_Icon_LargeClick here for a request form to amend your personal health information

Receive a notice that tells you how your health information is used and shared

You can learn how your health information is used and shared by your provider or health insurer. They must give you a notice that tells you how they may use and share your health information and how you can exercise your rights. In most cases, you should get this notice on your first visit to a provider or in the mail from your health insurer, and you can ask for a copy at any time.

PDF_Icon_LargeClick here for our privacy practices

Get a report on when and why your health information was shared

Under the law, your health information may be used and shared for particular reasons, like making sure doctors give good care, making sure nursing homes are clean and safe, reporting when the flu is in your area, or making required reports to the police, such as reporting gunshot wounds. In many cases, you can ask for and get a list of who your health information has been shared with for these reasons.

You can get this report for free once a year. In most cases you should get the report within 60 days, but it can take an extra 30 days if you are given a reason.

PDF_Icon_LargeClick here for an account of disclosures of your personal health information