Request for Access to Records

Center for Family Development

1258 High Street, Eugene, OR 97401 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 the following specific information:  

     I am requesting these copies for the following reason:  

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:

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:

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Signature Certificate
Document name: Request for Access to Records
lock iconUnique Document ID: 9c83fc00f2a22c659d056b8c6eb13fe69349754d
Timestamp Audit
May 29, 2020 11:49 am PSTRequest for Access to Records Uploaded by Jason Dooley - IP
June 2, 2020 4:27 pm PSTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip: