Request for Personal Health Information - Memorial Hermann ...

Form: Individual or Personal Representative Request of PHI
(Please fax completed form to Memorial Hermann Health Solutions Customer Service at 713-338-6550)
Individual:
I ____________ request access to my protected health information; contained in the designated record set
maintained by Memorial Hermann Health Solutions.
Or
Individual’s Personal Representative:
I ________________ request access to the protected health information of; ______________________ contained in
the designated record set maintained by Memorial Hermann Health Solutions. My relation to the member is
_______________________.
I have the right to access and request copies of whatever portions or the entirety of my health plan records. I
understand this request will require the collection of these records and that Memorial Hermann Health Solutions.
will arrange a convenient time and place for me to access this protected health information.
I request access to the following information:
From (date) ____________________ to (date) _________________________
From (date)_____________________ to (date) _________________________
Please check type of information to be accessed:
□ Customer Service – Designated
Record Set
□ Utilization Management-
Designated Record Set
□ Premium Billing – Designated
Record Set
□ Eligibility – Designated Record □ Claims – Designated Record Set
Set
□ Other, (specify) __________________________________________________________________
I would like protected health information to be provided in (check one):
□ Photocopy format □ Original documents for inspection
For Copies Only: I request that copies of my PHI be provided to me by the following method (check one):
□ Personal pick up □ US Postal Service to (Address):__________________________
□ Other, specify: ______________________________________
I request to access my PHI on the following date (1 st choice)___________ (2 nd choice) ______________
NOTE: This authorization is valid until 180 th day after the date it is signed unless it provides otherwise, not to
exceed 24 months, or unless it is revoked.
Written documents could be subject to associated fees, which would be discussed prior to distribution.
Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information.
Payment is due at the time of the release. If I request copies of this information, I agree to pay the associated fees.
I, the undersigned, have read the above and authorize the staff of Memorial Hermann Health Solutions an affiliate of
Memorial Hermann Health System to disclose such information as herein contained. I have the right to revoke this
authorization in writing at any time except to the extent that action has been taken in reliance upon it. I understand
that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by
the recipient and many no longer be protected. I hereby release and hold harmless the above named facility and its
parent company from all liability and damages resulting from the lawful release of my Protected Health Information.
________________ ________________________________________ __________________
Date Signature of Member/Parent/Conservator/Guardian Authority/Relationship to
Information on Member (PHI Form)
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Form: Individual or Personal Representative Request of PHI
Name:_________________________________________
Address:____________________________________________________________
Telephone:____________________________
Individual’s Date of Birth:_________________
Individual’s SS#:________________________
Date Request Received by Memorial Hermann Health Solutions __________________________
Identity of Requestor Verified via: □ Photo ID □ Matching Signature □Other, specify
Verified by: _____________________
Information on Member (PHI Form)
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