Patient Rights Forms
Authorization Form to Release Medical Information - ENGLISH
Authorization Form to Release Medical Information – SPANISH
Privacy Complaint – to be created - need form from content owner
Requesting an Amendment to Your Medical Record
- You have the right to request that we make amendment to clinical, billing and other records used to make decisions about you. We will evaluate and determine whether it is proper to comply with your request, and we will notify you in writing of whether we complied with your request. Typically, your request will be processed within 60 days of receipt of your completed request form. We will let you know in writing if there is a delay.
Requesting an Alternative Means of Communication
- You may request how and where we may contact you about PHI. We will accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment will be handled and your specification of an alternative address or other method of contact.
Use & Disclosure
Restricting the Use and Disclosure of Your Medical Records
- You may request that we restrict the use and disclosure of PHI about you, but we are not required to agree to your requested restrictions except in limited circumstances further described in the UNCHCS Notice of Privacy Practices.
Requesting an Accounting of Disclosures of Your Medical Record
- You have the right to receive a written list of certain disclosures we have made of PHI about you. If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. Typically, your request will be processed within 60 days of receipt of your completed request form. We will let you know in writing if there is a delay.