PATIENT REQUEST TO INSPECT PROTECTED HEALTH INFORMATION FORMS(100/CASE)

THE PATIENT WHO REQUEST TO INSPECT OR REVIEW PROTECTED HEALTH INFORMATION WILL BE ASKED TO COMPLETE THIS FORM THAT REQUIRES THE PATIENT TO PROVIDE INFORMATION REGARDING WHICH INFORMATION AND/OR DATES BEING REQUESTED. THE FORM, RETAINED IN THE PATIENT'S MEDICAL RECORD, ALSO ALLOWS YOU TO RECORD WHEN AND HOW THE RECORDS ARE REVIEWED, IF THE REVIEW IS DENIED, THE REASON FOR THE DENIAL AND THE DENIAL NOTIFICATION DATE.