WP E-Signature by Approve Me - Sign Documents Using WordPress -

Request for Access to Records

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Request for Access to Records

Date of Request: Phone Number: Name: Date of Birth:

I am requesting copies of information from my clinical record. If my request is approved, it may be determined that I review this information with my therapist or a Clinical Supervisor. If review is not necessary, I will be contacted within 5 business days of this request to be informed that my records are ready for pick up.

I am requesting copies of the following specific information:

I am requesting these copies for the following reason:

I am requesting a copy of my Accounting of Disclosures, if applicable.

I understand that my request may be denied. If my request is denied, CFD will provide me with a written explanation of the denial within 5 business days of this request. I may request that this denial be reviewed by a person other than the person who denied my request.

My signature affirms that I have read and understand this form and have had the opportunity to ask questions.

This document is being signed by: ClientPersonal Representative, see below

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

*** NOTE: There may be a charge for copies and staff time; however, access to records will not be denied because of inability to pay. ***

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

May 29, 2020 11:49 am PDT

Request for Access to Records Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202

June 2, 2020 4:27 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

March 18, 2021 2:47 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:47:19 - 65.157.96.202

March 18, 2021 2:47 pm PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

May 3, 2021 10:29 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202