Patient

Name: Last First MI Maiden orOther

Address:

City:ST:

Zip:

Date ofBirth:

Phone(____)______Emailaddress:

I request access to my protected health information maintained by this medical organization. I understand that this request will be considered and a response provided within the required state or federal timeframe. If my request is denied for any reason, I will receive a written explanation of the reason for the denial.

I understand that my medical record may contain sensitive information such as mental health, HIV, AIDS, substance abuse, sexual abuse and /or other related conditions. I understand that these records are classified as privileged and confidential and cannot be released to me or those designated by me or my legal guardian without an express and informed written consent. In addition, I understand that theserecordswillnotbereleasedtoentitiesotherthanthosedesignatedbymyselformypersonalrepresentative ofas providedbystateorfederallaw.

I understand that a form is required for each request for information.

I hereby request copies of information contained in my medical records to include the following:

DischargeSummary

TreatmentPlans

Labs

Immunizations

Progress Reports/ Notes

Social Development History X- Rays

Special Studies (EKG, Mammogram, etc.)

Psychological / psychiatricEvaluations

All of my medical records including sensitiveinformation (such as mental health,HIV,healthstatus,sexualabuseorsubstanceabuserecords)

_____ visit summaries

other(describe)

I authorize release/request of information covering treatment datesof:______

Requested method for responding to this request:

Received information today.

PapercopytobemailedbyUSPStoaddressindicatedabove.

Call attelephonenumberto notify me to pickup records.

Fax documents to me at :______(fax #).

*Email sent encryptedto:

*For security of your information, all emails are sent encrypted unless requested unencrypted with recognition of risk.

**Email sent unencryptedto:

** I understand that records sent through unencrypted email pose a security risk but it is my requested method.

PRINTED NAME OF PATIENT

SIGNATUREOFPATIENTDATE

OR



PARENT/LEGALGUARDIAN/AUTHORIZEDPERSON RELATIONSHIPTOPATIENT

______

Signature of Staff if patient is unable to sign


FOR INTERNAL USE ONLY

Complete the sections below and place in patient record.

Notice of Decision is: Approved and provided perrequestDenied for reason indicatedbelow.

Information requested is not part of patient’s designated recordset.

Informationrequestedisnotavailabletothepatientforaccessasrequiredbyfederalorstatelaw.

A physicianhasdeterminedthataccesstoinformationrequestedmayendanger the life orphysical safetyof the individual or anotherperson.

Other:

Staff Member whoprocessedrequestTitleDate

If denied, patient response letter will be sent.

Discrimination is Against the Law

Humana Inc. and its subsidiaries (“Humana”) complywith applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Humana Inc. and its subsidiaries do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Humana Inc. and its subsidiaries provide:

  • Free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aidsandservicesarenecessarytoensureanequalopportunitytoparticipate.
  • Freelanguageservicestopeoplewhoseprimarylanguageisnot Englishwhenthoseservicesare necessarytoprovidemeaningfulaccess,suchastranslateddocumentsor oralinterpretation.

If you need these services, call 1-877-320-2188 or if you use a TTY, call 711.

If you believe that Humana Inc. and its subsidiaries have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Civil Rights / LEP/ ADA/ Section 1557 Compliance Officer 500 W. Main – 10thFloor

Louisville, Kentucky 40202

If you need help filing a grievance, call 1-877-320-2188 or if you use a TTY, call 711.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at , or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

1-800–368–1019, 800-537-7697 (TDD)

Complaint forms are available at


English:ATTENTION:IfyoudonotspeakEnglish,languageassistanceservices,freeofcharge,areavailable to you. Call: 1-877-320-2188 (TTY:711).

Español(Spanish): ATENCIÓN: sihablaespañol, tiene a sudisposiciónserviciosgratuitosde asistencialingüística. Llameal 1-877-320-2188 (TTY: 711).

繁體中文(Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-877-320-2188（TTY:711）。

TiếngViệt(Vietnamese):CHÚÝ:NếubạnnóiTiếngViệt,cócácdịchvụhỗtrợngônngữmiễnphídànhchobạn.Gọisố1-877-320-2188(TTY:711).

KreyòlAyisyen(FrenchCreole):ATANSYON:SiwpaleKreyòlAyisyen,gensèvisèdpoulangkidisponibgratispouou.Rele1-877-320-2188(TTY:711).