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102 South Tejon St., ste 1100 Colorado Springs, CO 80903RECORDS RELEASE Patient Authorization for Disclosure of PHI (Not for Psychotherapy Notes) Patient Name: ___ Patient Address: ___ Patient DOB:
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Your rights regarding access refer to your legal entitlement to obtain information held about you by organizations and government entities.
Individuals or entities requesting access to their personal information are required to file for their rights regarding access.
To fill out your rights regarding access, complete the designated form provided by the organization holding your information, ensuring to include all required details and supporting documents.
The purpose of your rights regarding access is to empower individuals to know what personal information is held about them, how it is used, and to correct any inaccuracies.
You must report your full name, contact details, description of the information you seek, and any relevant identification or reference numbers.
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Relevant keywords

Patient authorization Disclosure of PHI Health record release Larson Mental Health Patient rights HIPAA compliance Mental health records Confidentiality Revocation of consent Patient consent form

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