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IM201-01-A Rev. 05/11

Patient Request for Access to Protected Health Information

This form must be submitted by patients to request inspection and/or copies of their protected health information. Please read the instruction page (attached) before completing this form. I. Patient name: _________________________________________________________ Birth date: ______________________ Mailing address: _________________________________________________________ Home phone: ____________________ City, State, ZIP:__________________________________________________________ Dates of service: _________________ II. I wish to (check one): _____Inspect the record _____Obtain copies of the record (fee schedule available in HIM Department)

III. I want to inspect or obtain copies of the following reports: ( ) Abstract - includes face sheet, discharge summary, history and physical exam, operative and pathology reports, consultation reports, radiology reports and EEGs Or: ( ) Discharge summary ( ) History and physical exam ( ) Consultation reports ( ) Progress notes ( ) Radiology reports ( ) Laboratory reports ( ) Pathology reports ( ) Operative reports ( ) Clinic/outpatient record Which clinic or doctor? ______________________________________ ( ) Billing claim forms ( ) Itemized statement of charges ( ) Other, specify: ____________________________________________________ ( ) All information

Or, for mental health records (may require physician/psychologist approval): ( ) Psychiatric/mental health records ( ) LSC/CAP records ( ) Neuropsychological testing ( ) Other, specify: ( ) All information Please note that currently Texas Children’s Hospital can provide only paper copies for most reports. IV. I request Texas Children’s Hospital (Texas Children’s) to provide me with access to the protected health information as described above. I understand the following:  The information released may contain information related to AIDS or HIV infection; drug or alcohol abuse; mental or...