INSTRUCTIONS: Print print the applicable form, and complete all information in blue or black ink. Submit the form according to directions written on the form.

Release of health records; notice of privacy practices

Please see patient rights forms related to your Protected Health Information (PHI) below.

Health forms

Department charge authorization

Protected Health Information (PHI) patient rights forms

The Health Insurance Portability and Accountability Act (“HIPAA”) gives you the right to make the following requests regarding your Protected Health Information (PHI):