If "TO PATIENT"

If "TO FACILITY/PROVIDER"

Request for Access to Protected Health Information

Under the Privacy Rule, a patient or his/her personal representative may request access to the patient’s protected health information (PHI) for the purposes of inspection and/or obtaining a copy of the PHI. There are conditions under which a healthcare provider may deny access to protected health information without an opportunity for the patient to have the denial of access reviewed. These conditions include:

1. Psychotherapy notes;
2. Information intended for use in a civil, criminal, or administrative actions;
3. When an individual (patient) is an inmate in a correctional facility or the healthcare provider is acting under the direction of correctional facility, where providing access to information would endanger other inmates or correctional employees;
4. When an individual (patient) has consented to the withholding of information as a subject in a research program that is still in progress;
5. When the Privacy Rule denies access; and
6. When the healthcare provider obtained the protected health information under a promise of confidentiality, and access to the information would reveal the source of the information.

There are three conditions under which a healthcare provider may deny access to protected health information but, if they do, must provide the individual (patient) or his/her personal representative an opportunity to have the denial reviewed. These conditions include:

1. When the healthcare provider has determined that access to the protected health information is likely to endanger the life or physical safety of the individual (patient) or another person;
2. When the information identifies another person, and the healthcare provider believes that access will cause harm to the other person; and
3. When the information is requested by a personal representative of an individual (patient) and, in the judgment of the healthcare provider, providing access to the information might subject the individual (patient) to domestic violence, abuse, or neglect by the personal representative.

Access (inspection and/or obtaining copies) to protected health information is provided on a scheduled basis. Please note that, due to privacy and risk management guidelines, original documents of protected health information may only be inspected in the presence of one of our staff members and original materials may not be removed from the facility. Our receptionist can provide scheduling information for you at the time of your request.

Once your request is reviewed and verified by an Alliance staff member it will be processed within 7-10 days. Our fees are based on current state fee structures. Patient Requestors for personal copies of their Protected Health Information are subject the cost of postage and the following fees:

• Paper Copy of Records = $10.00 flat rate if record is 25 pages or less. Additional pages after 25 are 20 cents each in addition to the cost of postage
• CDROM of Records = $10.00 flat rate per disc in addition to the cost of postage.

If you have any questions about this information, please contact Alliance Obstetrics & Gynecology at 517-484-3000.

Copies of signed authorizations are available upon request.

Expirations or termination of authorization: This authorization is a one-time request for the listed purpose and will expire 14 days from the date of this request. This authorization may be terminated at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization.

Redisclosure: We have no control over the entity you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization will no longer be the responsibility of the practice.

Secure Communication: Note that some fax and email transmission methods are not secure, and it is possible for your PHI to be compromised during transmission from our practice. Do not designate fax or email as your preferred method of disclosure if this is of concern to youThe practice places no condition to sign this authorization on the delivery of healthcare or treatment.

The practice places no condition to sign this authorization on the delivery of healthcare or treatment.

I have received the Request for Access to Protected Health Information handout.

Purpose of disclosure – To obtain or provide protected health information for the purpose of treatment