Request for Access to Protected Health Information (PHI)

I hereby request access to Protected Health Information (PHI) maintained by Women’s International Pharmacy, Inc. for the purpose of inspection and/or obtaining copies. Please note: Records will be sent by the method indicated below or may be picked up, in person, at the pharmacy, unless the person requesting PHI is an agent of the patient or the patient is requesting records be sent to another person.

Request for Access to Protected Health Information (PHI)

Patient Name*
First Middle Last
Patient Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Patient Phone Number:*
Patient Email (if applicable):
Patient Fax (if applicable):
To be completed only if patient is requesting PHI be sent to another person:
Person's name receiving PHI:
Person's address receiving PHI:
Person's email receiving PHI (if applicable):
Person's fax number receiving PHI (if applicable):
To be completed only if patient's legal representative is requesting PHI (provide proof of legal authority):
Name of Legal Representative:
Address of Legal Representative:
Telephone Number of Legal Representative:
Email of Legal Representative (if applicable):
Fax Number of Legal Representative (if applicable):
Information Requested
Information Requested:*
From:*
MM slash DD slash YYYY
To:*
MM slash DD slash YYYY
Format Requested:*
- Mail
- E-mail
- Fax
Select all that apply.
Signature*

(Patient or Legal Representative* signature required)
*If a legal representative of the patient signs the form, please also include one of the following: (1) a copy of the signed Power of Attorney, (2) other proof of legal authority, or (3) a signed patient release form.
Date*
MM slash DD slash YYYY

Request for Access to Protected Health Information (PHI)

Request for Access to Protected Health Information (PHI)

To be completed only if patient is requesting PHI be sent to another person:

To be completed only if patient's legal representative is requesting PHI (provide proof of legal authority):

Information Requested