NAME:______________________________________
BIRTH DATE:___________________
ADDRESS:__________________________________________________________________
TELEPHONE:_________________________________
DATE:________________________
REQUEST:
I
hereby request that The Counseling Center provide me with
(check
all boxes that apply):
Access to or
My own copy of the requested information checked below:
My medical records.
My billing records.
Any other personally identifiable information used by The
Counseling Center to
make medical decisions about me.
Please describe:____________________________
I am interested in access to all requested information maintained
by The
Counseling Center.
I am interested in obtaining a copy of all requested information
maintained by
The Center.
I am interested in accessing or obtaining a copy of the requested
information
relating to the following time period:
Start Date ______________________ through End Date ________________________
I would prefer to receive the requested information in the form of
a summary.
COSTS:
All
costs/charges for copying materials, chart review and summary report preparation
are the responsibility of the client requesting the information. A small charge
for postage may also be added if necessary. An estimate of the charges can be
provided once the amount and type of information being requested has been made.
NOTIFICATION:
I wish to receive the requested information in
the following format:
Photocopies
Electronic transmission (if available)
Other (if available)_______________________
Signature________________________________________
Date ____________
Signature
of Parent or
Guardian_______________________ Date ____________
|
Request
for access or copy is:
Accepted
Denied |
If denied, check the following
reason for denial:
PHI is not part of the clients designated record set.
Federal law forbids making the requested information available to
the client for inspection (e.g., CLIA or Privacy Act of 1974).
The requested information is psychotherapy notes.
The requested information has been compiled for legal proceeding.
The requested information was obtained under promise of
confidentiality and access would be reasonably likely to reveal the source of
the information.
Licensed health care provider has determined that access to the
requested information would result in physical harm to the individual or others.
Licensed health care provider has determined that the requested
information identifies a third person that may be physically, emotionally, or
psychologically harmed if access to the information is granted.
Licensed health care provider has determined that access to the
requested information by the clients legal representative could result in
harm to the individual.
We are acting under the direction of a correctional institution
and letting the inmate access or obtain a copy of the requested information
would jeopardize the health, safety, security, custody, or rehabilitation of
another person at the correctional institution.
The requested information is not maintained by our facility.
Right to Review:
You
do or you
do not have the right to a review
of this denial. Contact Privacy Officer to arrange for the review. If you are not satisfied with the outcome of the review, you
may file a complaint with me and/or The Counseling Centers Clients Rights
Officer Michael R. Hamill, LPC, LSW. Mr. Hamill may be reached at (330) 264-9029
weekdays from 8:00 am 5:00 pm. You may also file a complaint with the
Secretary of the Department of Health and Human Services.
_______________________________________________
_____________________
Diane
S. DeRue, MPA, LSW
Date
Compliance
and Privacy Officer
