RESPONSE TO RECORDS REQUEST

Sent To:

Date: ______

Name: ______

Address: ______

City, State: ______

On ______(date), you submitted a request to us pertaining to the records of ______(name of patient).

COMPLETE AS APPLICABLE:

  1. We are ready to prepare the  entire chart copy  summary (check one) you requested in  hardcopies  emailed copies  other ______(check one). The cost for this service is $______. Upon receipt of this charge, we will provide the requested records. Please contact our HIPAA Privacy Officer, ______, to arrange a time to pick up the records. If you prefer, we will mail them to you. Please call to determine the additional postage cost and let us know where you want us to mail the records.
  1. We are ready to provide you with access to inspect the records as you requested. Your appointment time if from ____ am/pm to _____ am/pm on ______at ______Please contact our HIPAA Privacy Officer at least 24 hours in advance if you will unable to make this appointment.
  1. We are denying  all  some (check one), of your request as indicated below because:

 We do not have the following records: ______

 We believe you may obtain those records by contacting: ______

 We do not know where you may obtain the records.

 We cannot produce the copy or summary in the format you requested.

Format we can deliver is: ______.

Please contact our privacy officer if you would like paper copies.

 We cannot give you access to the records because:

 You lack authority under state law to access these records (i.e. the patient has not given you authority in writing, the written authority has been revoked, the records are super-confidential and you have only a general authority).

 The information was given to us on a confidential basis and revealing the record would disclose the source of the information.

 The information has been compiled in anticipation of litigation

 The information is protected by the Clinical Laboratory Improvement Amendments of 1988 (42 U.S.C. 263a) or the Privacy Act (5 U.S.C. 552a).

 A licensed health-care provider has determined, in the exercise of his or her professional discretion that disclosing the records would endanger the health or safety of you or another person.

 Other: ______

If you disagree with our decision, you have the right to file a formal written complaint within 180 days with the U.S. Department of Health & Human Services.

FIND THE OFFICIAL FORM AT:

Find Regional Addresses at:

Office of Civil Rights, 200 Independence Ave., S.W., Washington, D.C. 20201, 877.696.6775

Thank You,

______

HIPAA Privacy Officer

HIPAA made EASY™

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