Authorization for Use or Disclosure of Protected Health Information (PHI)
An individual or family member may request access to the individual Protected Health Information (PHI) by completing this form. The form will be submitted to Richard Thompson, Director of Quality & Corporate Compliance/Privacy Officer.
Upon receipt of the completed form, a determination regarding the request will be made within the timeframes specified by the state and/or federal law. You will be notified promptly regarding the release of information being requested.