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
If you have questions about the contents of this document, you can email the document owner.
Document Name: Request for Access to Records
Agree & Sign