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1829 College Avenue Manhattan, KS 66502REQUEST TO ACCESS AND COPY PROTECTED HEALTH INFORMATION FORM Patient First Name: ___ Last Name: ___ Date of Birth: ___ Phone: ___Email Address (Optional): ___

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How to fill out request-to-access-and-copy-protected-health-information

01

Obtain the request form from the healthcare provider or facility

02

Fill out the form with your personal information and the specific information you are requesting

03

Provide a copy of a government-issued ID to verify your identity

04

Submit the completed form and ID to the healthcare provider or facility either in person, by mail, or through their secure online portal

05

Wait for confirmation from the provider that your request has been received and processed

Who needs request-to-access-and-copy-protected-health-information?

01

Individuals who want access to their own protected health information

02

Legal guardians requesting information on behalf of a minor

03

Authorized representatives acting on behalf of the patient

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What is request-to-access-and-copy-protected-health-information?

It is a formal procedure that allows individuals to request access to and copies of their protected health information (PHI) held by healthcare providers and organizations.

Who is required to file request-to-access-and-copy-protected-health-information?

Patients or their authorized representatives are required to file this request to obtain their protected health information.

How to fill out request-to-access-and-copy-protected-health-information?

To fill out the request, individuals typically need to provide their personal information, specify the health records they wish to access, and submit the request to the appropriate healthcare provider or organization.

What is the purpose of request-to-access-and-copy-protected-health-information?

The purpose is to ensure that individuals can review and obtain copies of their health records to promote transparency and empower patients in their healthcare decisions.

What information must be reported on request-to-access-and-copy-protected-health-information?

The request should include the individual's name, contact information, details about the records needed, and a signature or authorization if applicable.

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