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Request to Obtain Protected Information

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MPN 1772
Packaging 1 per each
Size 8 1/2In x 11In

    Note : Image shown for reference purposes only. Actual product appearance may vary. Please read product description for full and accurate details

    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.
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