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)

  • Date Format: MM slash DD slash YYYY
  • 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

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
    Select all that apply.
  • (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 Format: MM slash DD slash YYYY