Client Request for Records

Client Request for Records
Date of this Request

MonthDayYear
Date
Legal Name*
Date of Birth *

MonthDayYear
Date
SSN*
Phone Number*
Email
example@example.com
Address*

Address

Street Address Line 2

CityState

Zip Code
Treatment Information

I was treated in the:
I was treated in the following:*

Outpatient Substance Use ProgramResidential Substance Use ProgramMental Health Services
Outpatient Substance Use Program From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Residenital Substance Use Program From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Mental Health Services From Date:

MonthDayYear
Date
To Date:

MonthDayYear
Date
Record Requested

I have INITIALED the health records I am requesting
Substance Use Records

SUD Comprehensive AssessmentSUD Individual Treatment PlanSUD Weekly Treatment PlanSUD Discharge SummaryOther
Medical Records

Medication ListComprehensive Medical AssessmentUA & LabsType option 4Other
Mental Health Records

Diagnostic AssessmentMH Individual Treatment PlanMH Discharge SummaryPsychological TestingOther
Delivery Preference
I request to receive my health records via the following method (please check one):*

In PersonVia Mail (sent to the address listed above)Through Secure Email ( sent to the email listed above)
Aknowledgment
I am requesting a copy of my health records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations. I acknowledge that the records I request will be delivered according to my selected delivery preference. I understand that email is not a secure method of transmission for confidential health information and, therefore, request to receive the records via secure email only or other method unless otherwise indicated. I look forward to receiving my records within 30 days, as specified under HIPAA. If my request cannot be honored within 30 days, please inform me in writing with an estimated date of fulfillment.
Print Client Name*
Client Signature*

Clear
Parent or Guardian if applicable
Signature of Parent or Guardian

Clear
Should be Empty:

Client Request for Records

Treatment Information

Record Requested

Delivery Preference

Aknowledgment