Data Access Request - Hospital-Level Care at Home

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Protected Health Information Access / Disposal Request Form

Instructions: Please complete the following form to request access to or disposal of Protected Health Information (PHI).

Request Type:

Access RequestDisposal Request

Requester Type:

SelfThird Party

Personal Information (Requester):

Nameyour full name

Your Relationship to Patient (” self” if you are the patient):

Patient's Full Name:

Patient's Date of Birth:

Contact Information:

Your Email:

Your Phone

Verification Document (Upload):

Upload a scanned copy of a government-issued ID or insurance card of the requester, and, if not the patient, a document verifying your relationship to the patient (e.g., birth certificate, power of attorney, legal authorization).

Fileupload

Upload

Request Details:

Please provide a brief description of the information you are requesting access to or wish to have disposed:

0 /

I hereby request access to the Protected Health Information of the patient named above, or request disposal of specific PHI, as allowed by law.

Signature

Date

Note: Your request will be processed according to applicable laws and regulations in no longer than 30 days from the date of receipt of completed form. By submitting this request, you agree to the terms outlined in our Privacy Policy

If you have any questions, please contact us at (609) 888-6039

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