Saint Therese Home, Inc.
RESIDENT REQUEST TO ACCESS PROTECTED HEALTH INFORMATION
Resident Name ___________________________ Medical Record #_______________
Other Name(s) ____________ DOB __________ Social Security #________________
I request that St. Therese provide me with access to my personal health information as checked below:
q Medical Records
q Billing Records
q Other ____________________________
I request access to my health information covering the dates ___________ through __________.
q Copies
of requested information
I understand that St. Therese may charge a fee for the costs
of copying, mailing or other supplies associated with my request. Please allow staff three days to complete
request
Please mail information to: ____________________________________
____________________________________
____________________________________
q Inspection
of my health information at the facility
Please contact ________________________ to arrange a mutually convenient time for
(Name of facility
contact)
inspection.
_____________________________ ____________________________________
(Address) (Phone
Number)
_____________________________ ____________________________________
Signature
of Resident/Responsible Party Relationship
to Resident if Signed by Resp Party
_______________________________ _______________________________________
Date
of Resident’s Responsible Party’s signature Reason
Resident Unable to Sign