SIH Medical Group
PATIENT I PERSONAL REPRESENTATIVE REQUEST FOR ACCESS TO HEALTH INFORMATION
Patient Name
Patient Date of Birth
MM
/
DD
/
YYYY
Name of SIH MG Provider/Practice
Date(s) of Service
From
01
/
01
/
2000
through
01
/
01
/
2000
Specific Health Information Requested
Lab Report
Pathology Report
Imaging Report
EKG
Immunization Record
Physical
Office Visit Note
Other:
Date(s) of Service requested:
From
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.
Choose one:
Printed on Paper
PDF burned to CD
Electronic computable/machine readable file
How do you want to obtain a copy?
Delivery Method
I will pick up
Mail to me at address below
Send to another healthcare provider/healthcare organization at the address below
Email unencrypted to me:
Send to MyChart
Fax to another healthcare provider/healthcare organization:
Name
Address
Name of Healthcare Provider/Healthcare Organization
Fax #
My Email
Terms of Service
I agree to the
terms of service
.
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.
Signature
(Patient/Legal Representative)
Clear
Date
MM
/
DD
/
YYYY
*We ask for your signature as a method to further verify your identity and protect your health information from wrongful access by others.
Choose one:
I am the patient
I am the patient’s legally authorized representative/agent
Legally authorized representative First / Last name
Legally authorized representative phone number
If signed by other than the patient, please indicate legal relationship
Verification
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3
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7
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