Access to PHI Form

Southwest Shiawassee Emergency Services Alliance

Patient / Next of Kin Request for Access to PHI Form
Patient Name:

First NameLast Name
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Rights: As a patient/Next of Kin, you have the right to access, copy or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. You also have the right to receive the PHI in an electronic format and/or at a location other than your residence. These rights are further described in our Notice of Privacy Practices.
Review my health information.Obtain copies of my health information.Review and potentially request amendment of my health informationReview and potentially request as accounting of how my PHI has been used and disclosed to others.Review and potentially request restrictions on the use and disclosure of my health information.
Self (Patient)SpouseChildPower of AttorneyOther
If "Other" please specify:
Request is for the following date(s) of service:
Enter Month - Day - Year
In person viewingElectronic via EmailPaper via FaxPaper via Mail
Please provide the information needed to process your requested format.
Email
example@example.com
Fax Number
Please enter a valid fax number.
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Requestor

Clear
Name of requestor, if other than the patient

First NameLast Name
Requesting Party, upload a picture of your photo I.D.

Cancelof
Should be Empty:

Southwest Shiawassee Emergency Services Alliance