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. ***