Transcription of Request to access, inspect, or obtain protected health ...
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Request to access, inspect, or obtain protected health ...
walgreens Custodian of Records, 1901 East Voorhees Street, MS 735, Danville, Illinois 61834 Fax: (217) 554-8955 Phone: (217) 554-8949 Request TO access , inspect , OR obtain protected health INFORMATION Request : I Request to review health information held about me in the walgreens designated record set in accordance with the health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that walgreens has 30 days to respond to this Request , walgreens may extend this 30 day response period for another 30 days, and in certain circumstances walgreens may deny my Request . Information: Patient Name: Date of Birth: Street Address: City, State, Zip Telephone Number: ( ) E-mail Address: Standard requests for records contain a fifteen (15) month time period.
REQUEST TO ACCESS, INSPECT, OR OBTAIN PROTECTED HEALTH INFORMATION Request: I request to review health information held about me in the Walgreens “designated record set” in accordance with the Health Insurance Portability and Accountability Act of …
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