REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION

REQUEST FOR ACCESS TO PROTECTED HEALTH INFORMATION
Instructions

Please complete this form in its entirety to request copies of personal health information maintained by CCH Pediatric Clinic, P.C.

Once your request has been processed, we will notify you when your records are available for inspection or pickup, or when they have been sent as requested. If applicable, you will also be informed of any fees associated with your request.

Please allow 7-10 business days for processing.

Please note that certain requests may be denied as permitted by applicable law. If your request cannot be fulfilled, you will receive written notification explaining the reason for the denial.

To request records, you must be the patient's parent or legal guardian with authorization to access the patient's medical information as documented in the patient's medical record.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates of service or time period of records requested: Specific time period or "all" field. Please add appropriate fields and text.
Please check below the information which you would like to review (You may check more than one box):

Other
If you choose other, please specify.
PLEASE DESIGNATE THE METHOD OF REVIEW
If you choose other, please specify.
If you request by email, please list the email address you would like it sent to. By providing an email I understand the risks in receiving my protected health information via unencrypted email and that it may be read by a third party.
example@example.com
If you wish to have the records mailed to you, please provide the address you would like it to be mailed to.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fees and Processing Time
1. A processing fee of $20.00 will be charged for handling your request.
2. A copying fee of $0.10 per page plus postage will apply.
3. A supply fee will be charged for a USB copy.
4. Total fees will not exceed $25.00
5. We require 7-10 business days to complete your request.
6. You will be notified when your request is complete.
Name of Patient/Parent/Guardian
Relationship to the patient:
Date

MonthDayYear
Date
By signing below, you authorize the release of your protected health information as requested above.
Should be Empty: