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2. 
4. Patient Name
5. Date of Birth
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Date of Service
17. Patient Rights
    As a patient, you have the right to access, copy, or inspect your protected health information, or PHI, in accordance with federal law. You may also have the right to request an amendment to your PHI, or request that we restrict the use and disclosure of it. These rights are further described in our Notice of Privacy Practices and in other policies, which you may have upon request.
19. To better allow us to process your request, please indicate the type of request you are making:

    Check all that apply

    1. Access to simply review my health information
    2. Access to obtain copies of my health information ($5 Record Copy Fee applies)
    3. Access to review and potentially request amendment of my health information
    4. Access to review and potentially request an accounting of how my PHI has been used and disclosed to others
    5. Access to review and potentially request restrictions on the use and disclosure of my health information
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

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