Health information request – client or authorized representative

A Health Information Access Request form is required client/authorized rep can choose from formal and informal request.

Heath InformationAccess Request Form

• 1 piece of photo identification (ID) or two pieces of non-photo ID is required to confirm identity.
• If you are requesting records for another individual, attach evidence of your legal authority to exercise that power (for example: guardianship order; power of attorney; excerpts from a will naming you as executor and the date and signature of the will).
• Please submit all requests to [email protected]