SIH

SIH Medical Group

PATIENT I PERSONAL REPRESENTATIVE REQUEST FOR ACCESS TO HEALTH INFORMATION
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Date(s) of Service requested:

I understand the records I am requesting may include disclosing information regarding mental health, development disability, sexual orientation/gender identity, sexually transmitted disease, alcohol and/or drug abuse services and HIV/Aids test results, including but not limited to examination, diagnosis, evaluation, treatment or rehabilitation.

How do you want to obtain a copy?

There is no charge if you are requesting the health information be mailed or faxed to another healthcare provider for treatment purposes. Depending on volume of health information requested, format requested and delivery method, there may be a cost-based fee charged.
(Patient/Legal Representative)
 
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*We ask for your signature as a method to further verify your identity and protect your health information from wrongful access by others.
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