HIPAA Request for Access to Health Information

In accordance with the U.S. Health Insurance Portability and Accountability Act ("HIPAA"), 45 C.F.R. Part 164.524:

1. I hereby request that the Provider named above and its Business Associates, provide me with the following protected health information ("PHI"), to the extent contained in any of Provider's (or Business Associate's) Designated Record Sets (as defined by HIPAA) (the "Requested Files").

The PHI I request includes all written Care Plans (also called Plans of Care, Treatment Plans, Discharge Summaries, Continuity of Care Plans, Encounter Notes, Patient Summary), and all X-Rays/Radiographs created for me in (the month/year after this request).

2. I hereby request that the Provider prepare all Requested Files so as to include all original contents exactly as stored in the Provider's on-site or archived paper or electronic health record systems and, if applicable, exactly as submitted for reimbursement to public or private health insurance plans.

3. I hereby request that the Provider format Requested Files in pdf file format for Care Plans and in jpg or png file format for x-rays/radiographs.

4. I hereby request that the Provider upload Requested Files to my RK360 Cloud Record by clicking on this link or entering this URL in a web browser.

5. In order to assist the Provider in the verification of my identity, copies of my (and, if applicable, my Personal Representative's) identification and health insurance card(s) are attached to this request.

6. As per HIPAA regulations, I ask that you supply Requested Files no later than 30 days from this request. If files cannot be provided, if Provider requires an extension of time to respond, or if Provider denies access permitted under HIPAA, please send relevant notifications in writing to me at: {patient_email}.

7. A copy or fax of this authorization will be as valid as the original.I certify that this request is made voluntarily and that the information given above is accurate to the best of my knowledge.