HIPAA Rights Request Form

HIPAA Rights Request Form
Date *

Month Day Year
Patient Name *

First Name Middle Name Last Name
Patient Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Patient Phone Number *

Area Code Phone Number
Number
E-mail
Type of Request *
Please describe nature of action requested (type of information requested; nature of amendment, restriction, alternative communication, or complaint, etc.) in detail.

[Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below.]
Describe Here *
Please list Samaritan EMS staff members that were contacted regarding this matter:
Name *
Date *

Month Day Year
Name
Date

Month Day Year
Signature *

Clear
Should be Empty: