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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:
Requester Type:
Personal Information (Requester):
Contact Information:
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).

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

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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