HIPAA Rights Request Form

HIPAA Rights Request Form
Date*

MonthDayYear
Patient Name*

First NameMiddle NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Patient Phone Number*

Area CodePhone 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*

MonthDayYear
Name
Date

MonthDayYear
Signature*

Clear
Should be Empty: