Academics & Research

Your Rights Concerning Your Health Information

Requests marked with a star (*) must be made in writing. (A form is provided for your convenience).

Receive a copy of our privacy notice.
Notice of Privacy Practices - English
Notice of Privacy Practices - Spanish

Receive a copy of your paper of electronic medical record.*
Patient Authorization to Disclose Protected Health Information form

Correct your paper or electronic medical record.*
Patient Request to Amend Protected Health Information form

Request confidential communication.*
Patient Request for Alternate Method of Communication form

Ask us to limit the information we use and share.*
Patient Request for Special Privacy Restriction form

Ask us NOT to share certain health information with your insurer.*
Patient Request for Special Privacy Restriction When Self Pay form

Get a list of those with whom we have shared your information for reasons other than treatment, payment, or administrative purposes.*
Patient Request for Accounting of Disclosures form

Choose someone to act for you.*
Legal documentation of your choice is necessary.