BH Request to Access PHI

REQUEST TO ACCESS PROTECTED HEALTH INFORMATION

Behavioral Health Programs
Client Name *

First NameLast Name
Birth Date*

MonthDayYear
Date
AzCA Office or Program
I am requesting Protected Health Information (PHI) from Arizona's Children Association (AzCA). I would like access to the following information from the medical record:

Progress NotesContact NotesAssessmentService PlanCrisis & Safety PlanPsychiatric EvaluationMedicationsLab ResultsDischarge SummaryAll Medical RecordsOther
Release to Other Agency
Is this a DCS Records Request?*

YesNo
Would you like to release records to another agency?*

YesNo
Name of Agency:            First Name   Last Name
Email:
Phone Number: Area Code   Phone Number
Address: Street Address      City   State   Zip
TIMEFRAME AND TYPE OF REQUEST
I request records FROM the following time frame: Date TO the following time frame: Date .
I request access in the following format:

Paper copy(mail, pickup, fax)Electronic copy (E-mail)
I can be contacted at:
Email: *
Phone Number: Area Code*   Phone Number*
Address: Street Address*      City*   State*   Zip*
Guardian ID required - please upload ID*

Cancelof
EXTENSIONS AND FEES

I understand that AzCA must grant me the requested access within 30 days, unless the information is not readily available, in which case AzCA shall grant me access in 60 days. AzCA may extend these periods by an extra 30 days (or less) to prepare the information I have requested and shall notify me if this is necessary.

YOUR RIGHTS

For more information about your privacy rights, see the “Notice of Privacy Practices” available on our web-site at www.arizonaschildren.org or by sending a written request to Arizona's Children Association (AzCA), 3636 N. Central Ave. Phoenix, AZ 85012.

If you believe your privacy rights have been violated, you may file a complaint with AzCA or with the Secretary of the Department of Health and Human Services. To file a complaint with AzCA, contact the AzCA’s Privacy Officer at 3636 N. Central Ave. Phoenix, AZ 85012. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
SIGNATURE OF CLIENT/PARENT/LEGAL GUARDIAN
Sign Date:

MonthDayYear
Date
Full Name *

First NameLast Name
Relation to Client *
Parent, legal guardian, etc.
Signature

Clear
Email (optional):
example@example.com
Should be Empty:

REQUEST TO ACCESS PROTECTED HEALTH INFORMATION

Release to Other Agency