PHI Request Form

The Northampton Center for Couples Therapy

Form to Request Access to Personal Healthcare Information
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Date of Birth

Month Day Year
Date(s) or the part of client's record to be accessed
Type(s) of information to be accessed
I have consulted with the privacy officer about these records and information and have decided that I want:

to read and review the original records or photocopies of them. to read and review the original records or photocopies of them with a professional.
In reviewing these records, I would like (select all that apply)

to receive a photocopy of these records. to receive a summary of the information in these records. to receive a written explanation of the information in these records
Costs

I have been advised of the cost of copying, postage, or providing a summary or explanation and have agreed to pay the amount I have revised my request from my previous one.
Signature of client or legal representative

Clear
Date

Month Day Year
Date
Should be Empty:

The Northampton Center for Couples Therapy