Date(s)

631
Form
A.
Clients
Telephone______________________
(On your
to Clients
request
or
letterhead)
Address
the part
Form
access
name
________________________________________________________
ofto_________________________________
torequest
clients
personal
access
record
Other
healthcare
identification(s)
to
ones
be
accessed
information
health ___________________________
information
Date
_____________________
of birth ____________
_______________________________________________________________________
Type(s)
B.
_______________________________________________________________________
Iofhave
information
consultedtowith
be accessed
the privacy
_______________________________________
officer about these records and inform
qation andtohave
readdecided
and review
thatthe
I want
original
(select
records
one)or photocopies of them
them.with a pr
Time andIother
qofessional.
toplace
want
receive
_______________________________________________________________
this
to doacopy
photocopy
summary
written
the mailed
aboveexplanation
ofof
____________________________________________
thethese
to
meinformation
q at
records
ofthe
theabove
in these
information
address
records.
inorthese
at q ___________
records..
C.
q_____
ICosts
have(select
been advised
one) of the cost of copying, postage, or providing a summ
qary or Iexplanation
have revised
andmyhave
request
agreed. See
to pay
a version
$ _______
of this
.
form dated ___________
_________________________________
_______.
Signature
of client or legal representative
____________________
Printed name _____________
Description
_______________________________________________________________________
Date
D.
1.
qDecision
of personal
Iawill
of the
comply
representatives
health
withcare
thisprovider:
request.
authorityI will provide these records i
n the form
2.
q requested
I denywithin
this request
30 days for
of receiving
the reason(s)
this listed
request.below. You may not
appeal my decision.
q
The
q information
I believe
do notyou
know
that
arewho
this
seeking
hasinformation
this
is not
information.
inismyinrecords.
the posses
sion of ________________
q
I choose not to allow you access to my Psychotherapy no
tes.
q
The information was or is compiled in reasonable anticip
ation of, or for use in, a civil, criminal, or administrative action or proceedi
ng.
q
The information was obtained as part of a research progr
am you agreed to participate in and you agreed to a temporary suspension of your
right to accessqthis information.
The information is not available to the client for inspe
ction as permitted by federal law. For example, the access is illegal under the
Privacy Act, 5 U.S.
q C. The
552a.
information was obtained from someone who is not a h
ealthcare provider and they were promised confidentiality, and your viewing of t
his information qwould reasonably
Other reason
reveal
___________________________________________
the source of this information.
_______ q.
3.
I will partly comply with this request. I have removed parts of
the record and will allow access to the remaining parts. My reasons for removin
g those parts areq that: The
I choose
information
not to was
alloworaccess
is compiled
to my in
psychotherapy
reasonable anticip
notes.
ation of, or for use in, a civil, criminal, or administrative action or proceedi
ng.
q
The information was obtained as part of a research progr
am you agreed to participate in and you agreed to a temporary suspension of your
right to accessqthis information.
The information is not available to the client for inspe
ction as permitted by federal law. For example, the access is illegal under the
Privacy Act, 5 U.S.
q C. The
552a.
information was obtained from someone who is not a h
ealthcare provider and they were promised confidentiality, and your viewing of t
his information qwould reasonably
Other reason
reveal
___________________________________________
the source of this information.
________q.
4.
I deny this request for the reason(s) listed below. As a licens
ed healthcare professional, it is my professional judgment that your access to t
his information qis reasonably
endanger
likely
yourtolife or physical safety or that of another
person.
q
cause substantial harm to another person, who is not a h
ealthcare provider
q but iscause
referred
substantial
to in the
harmrecord.
to the individual or to another p
erson if your personal
q
representative
Other reason(s)is________________________________________
allowed access.
_______
If
you disagree
.
with my decision made for the reasons in section 4, above, you m
ay have my decision reviewed by a licensed healthcare professional who did not p
articipate in this decision. I will obey the decision of this person. This deci
sion will be made within 30 days of receipt of this form, you will be notified w
ithin 15 days after that, and I will act on the decision also within15 days of b
eing told of it. To arrange this review, check the box below. You may also file
a complaint about my decision with the Secretary of the DHHS. Our privacy office
r will assist you in doing this. If you have any questions or want to know more,
_______________________________________
Signature
Privacy
qAddress
please I,
contact
Officer:
________________________________________________________________
oftheHealth
client,
the
NameCare
Privacy
_____________________________
disagree
Practitioner
Officer.
with your, the healthcare
________________________
PhoneDate
professionals
_______________decision
and want an independent review.