Request for Access to Protected Health Information

Instructions

Please complete this entire form to request inspection or copies of your personal health information maintained by Chase County Community Hospital/Clinic.  We will notify you when your request has been processed and the records are ready for inspection or have been copied and the fee for your request.  There are certain circumstances in which your request may be denied.  If your request has been denied, you will be notified of the denial and the reasons why.  CCCH/CCC cannot process your request if this form is not complete.

Patient Name:                                                                             D.O.B:                                              

Current Address:                                                                                                                                  

Phone No.:                                                                                  Acct. No.:                                          

Dates of service or time period of records requested:                                                                              

(State a specific time period or “all”)

Please check below the information which you would like to review (you may check more than one box):

¨   Medical record

¨   Billing record

¨   Other (be specific):                                                                                                                         

Please designate the method of review:

¨   Receive copy by regular mail at the following address:                                                                      

      I understand that for anything over 5 pages, I will be                                                                        

charged a $5.00 handling fee as well as $0.50 per page.                                                                    

¨   Inspect the information at CCCH/CCC.  Information will be available at CCCH/CCC during normal business hours for inspection.

¨   Inspect the information at CCCH/CCC and receive a copy at the time of inspection.  I understand that for anything over 5 pages, I will be charged a $5.00 handling fee as well as $0.50 per page.

Signature of patient or patient’s personal representative                       Date

Authority of personal representative                                                   Witness

we will not process this request unless it is signed by you or your representative