REQUEST FOR ACCESS TO PROTECTED

HEALTH INFORMATION IM 104a

Name (Patient or Representative) Street Address/PO Box

City/State/Zip Telephone Number

I, being either the patient or the patient’s authorized representative, hereby request that CarePartners Health Services (“CarePartners”) provide access to the protected health information (PHI) maintained by CarePartners as specified below. I understand the right to access PHI applies to health information as defined in CarePartners’ designated record policy. It does not apply if the patient’s physician or treating mental health therapist determines that disclosure may be detrimental to the patient’s mental or physical health or to information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. Psychotherapy notes, as defined in 45 CFR 164.501, will also be excluded from access unless specifically authorized herein.

Patient Name: Date of Birth:

Protected Health Information Requested (check all that apply):

¨ Entire Record (Note: Please check Other and specify if you require duplication of media such as films, photos, and videos.)

¨ Assessment/Evaluations

¨ Bill/Statement of Charges

¨ Discharge Summary – Medical

¨ Discharge Summary – Therapy

¨ History and Physical

¨ Physician Notes

¨ Treatment Plans

¨ Visit/Progress Notes

¨ Other (please specify):

Requested Format (check one): o CD o Paper

Access Requested (check one):

p  Obtain a copy of the protected health information.

o  To be mailed to: (Write “Same” if same as name and address above.)

Name/Agency Street Address/PO Box

City/State/Zip Telephone Number

o  To be picked up at CarePartners by:

Printed Name (photo ID required upon receipt)

p  Inspect the protected health information CarePartners’ facility.

(continued from reverse)

I understand that information in the patient’s health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

Special Authorization: Psychotherapy notes are notes that may have been created by a treating mental health therapist and kept separate from the rest of the medical record. They are the personal notes of a treating therapist and provided a higher level of confidentiality. The treating therapist retains the right to determine whether or not the release of psychotherapy notes is in the best interest of the patient. Note: Counseling notes documented in the medical record do not require special authorization.

I authorize access to and/or request copies of any psychotherapy notes that may have

been created during the course of my treatment, unless it is prohibited by law or my treating therapist has determined access is not in my best interest (per CarePartners Policy IM-131).

Unless otherwise revoked, this authorization will expire 90 days from the date of signature or on the following date, event or condition: ______. Any revocation will not apply to information that has already been released based on this authorization or when the law provides the right for disclosure.

I understand that a fee may be charged for the following services related to this request: the preparation of a summary or explanation of the protected health information; reproduction costs to obtain a copy of the protected health information or to obtain a copy of the summary or explanation of the protected health information; mailing costs if I request to have the information mailed; the cost of the electronic media on which the copy is stored and provided; and for the labor costs associated with making the copy if I request an electronic copy of the protected health information. Fees for copies are based on North Carolina General Statute 90-411, which the North Carolina courts have found to be reasonable.

Signature of Patient or Representative* Date

Printed Name

*Relationship of Representative to Patient:

Rev. 09/16, Page 1 of 2

Community CarePartners, Inc. ● 68 Sweeten Creek Road ● Asheville, North Carolina 28803 ● 828.274.9567

REQUEST FOR ACCESS TO PROTECTED

HEALTH INFORMATION IM 104a

o Executor of Estate1

o Healthcare Power of Attorney1

o Legal Guardian1

o Parent2

o Spouse2

o Other3: ______


1 Legal documentation required with form submission.

2 Statement within CarePartners’ medical record identifying such relationship may be considered proof of relationship.

3 Documentation requirements will depend on relationship. Please contact CarePartners HIMS Department.

Rev. 09/16, Page 1 of 2

Community CarePartners, Inc. ● 68 Sweeten Creek Road ● Asheville, North Carolina 28803 ● 828.274.9567