Request to Obtain Protected Information

In stock
Reviewed and complies with the HIPAA Mega Rule! Patients / Residents wanting to review or obtain a copy of protected health information must submit a request. This one-page form simplifies the process and captures all the necessary information for the provider to consider the request.

Briggs offers a complete line of HIPAA documentation. Also see:
Notice of Privacy Practices / Acknowledgment of Receipt - Updated!(Stock No. 1770)
Business Associate Agreement - Updated!(Stock No. 1771)
Authorization to Release Patient Information (Stock No. 1773 or 1773/2)
Request for Amendment of Information (Stock No. 1775)
Denial of Amendment (Stock No. 1776)
Disclosure Log - Updated! (Stock No. 1779)
Confidential Patient Sign-In Log (Stock No. 1791)
8 1/2" x 11", white paper, printed one side, black ink, 5-holes punched top and side, padded in 100s.
More Information
MPN 1772
Packaging 1 per each
Size 8 1/2In x 11In
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