Request to Access Patient Records
This form is HIPAA compliant and secure for submitting personal identification information. If you have any questions or concerns, please do not hesitate to contact the pharmacy directly (404) 815-1610.
Patient Name
First Name
Last Name
Patient Date of Birth
-
Month
-
Day
Year
Date
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Phone Number
-
Area Code
Phone Number
Patient Email
example@example.com
Information Request
Type of Protected Health Information (PHI):
Medical Expense Summary (summary of all prescription expenses)
Designated Record Set (entire medical record maintained by the pharmacy) - Fees may apply
Insurance Claim Form (Universal claim form for a compounded medication)
Dates of Service
Previous calendar year
Receiving Format
Printed copy - Store pickup
Printed copy - Specify mailing address (Following Question)
Email (Unencrypted) - Specify email address (Following Question) By selecting this method of delivery and signing this form you are acknowledging and understand that an unencrypted email exposes your personal and health information to additional security risks.
If you selected printed copy mailing or email, please specify the mailing address or email address to send the records.
Signature
I understand that I am allowed to have access to these records and that the information will be provided to me in either hardcopy or electronic form. I understand that this request does not apply to certain health information, including: (1) information that is not held in the designated record set; (2) information compiled in reasonable anticipation of or for litigation; and (3) other information not subject to the right to access information under HIPAA.
Signature of Patient or Personal Representative
Clear
Signature Date
-
Month
-
Day
Year
Date
Name of Personal Representative (If applicable)
First Name
Last Name
Relationship to Patient (if applicable)
Submit
Should be Empty: