Asheville Pulmonary & Critical Care Associates, P.A.
Patient Request for Access to Medical Records
Patient Name: ______
Date of Birth: ______
Patient Chart: ______
Date of request for access: ______
Choose one of the following:
[ ] I would like to view my medical record. I have / will schedule (d) an appointment to view my health information
on ______. I understand a staff member of Asheville Pulmonary & Critical Care Associates, P.A. will be present during my review and will not be able to answer questions concerning my medical record. If I have questions after reviewing my health information, I understand an appointment will be scheduled with my physician and I will be responsible for payment of this consultative visit as insurance may not be filed. The charges for this consultative visit will be based upon the amount of time required by the physician and the charges may range from $40.00 to $200.00. Payment will be due the day of the consultative visit and may not be charged to my medical account with Asheville Pulmonary & Critical Care Associates, P.A.
[ ] I would like a copy of my medical record. I understand that I will be charged a fee based on Asheville Pulmonary & Critical Care Associates, P.A. fee schedule in compliance with federal and state law. I understand that I will be required to pay the fee in full before I can obtain the copy of my records.
[ ] I would like to pick up my chest x-ray. I understand that I am responsible for returning the chest x-ray to Asheville Pulmonary & Critical Care Associates, P.A.
Description of information to be released: ______
*Please indicate in the description if you are requesting the entire chart.
Please indicate how you would like your copies / x-ray delivered (pick-up*, mail, fax, etc.) If mailed, postage fee will be charged.
______
*For pick-up, please indicate the person that is authorized to pick-up the records and / or x-ray
I understand that Asheville Pulmonary & Critical Care Associates, P.A. is given thirty (30) days to process my request for access if my information is maintained on-site, sixty (60) days if the information is maintained off-site, and that Asheville Pulmonary & Critical Care Associates, P.A. may extend the deadline by an additional thirty (30) days if I am notified in writing of the extension. I further understand that my rights are limited to any information in my “designated record set” as defined in the Code of Federal Regulations.
Asheville Pulmonary & Critical Care Associates, P.A.
30 Choctaw Street
Asheville, North Carolina 28801
Phone: (828) 255-7733 Fax: (828) 258-3084
By signing below, I acknowledge and agree to the above conditions:
______
Signature of Patient or Authorized Person (Documentation of authority required):
______
Witness:
______
Date: