Authorization for Release of Records & Request for Records

REQUEST FOR ACCESS TO PATIENT’S HEALTH INFORMATION 

As a patient of Rosemark WomenCare Specialists, you are entitled under Federal law to access your Personal Health Information (PHI). Your records are protected and cannot be disclosed without your written permission.  A $5.00 PROCESSING/COPYING FEE WILL BE CHARGED FOR EACH MEDICAL RECORD REQUEST. Please allow approximately one week to process your request after completing this form.  If you have any questions or concerns regarding the handling of your PHI, or if you wish to view your PHI, contact our Privacy Officer at (208) 557-2940. 

Requested By:

Name of Patient: _____________________________    DOB: ________________

Address: ____________________________________   Phone No: _____________

City, State, Zip: _____________________________    SSN: _________________

Records to Come From:

Name: _____________________________________    Phone No: ____________

Address: ___________________________________     Fax __________________

City, State, Zip: _____________________________    Date Records Required: ______

To be released to:

Name: _____________________________________       Phone No: _____________

Address: ___________________________________       Fax ___________________

City, State, Zip: __________________________     Date Records Required: ________

Reasons for Request: [] Changing Doctors/Practices [] another Doctor Consultation [] for own Use

Requested Records: [   ] Entire Chart    [   ] Partial Chart-Date Range: ___________  to ______________  [   ] Labs: ____________________________              ________________________________

Signature of Patient or Representative if patient is a minor          

___________________________________________

Please print name of patient     

 ____________________________                                

Witness       

________________________

Date of Request:____________________