Please provide Doctor's name, address, and phone (if you know it)
Medical Records Request ---
I give Dr Christopher Highley, Preferred Family Medicine permission to request copies of my medical records as allowed by the Health Insurance Portability and Accountability Act (HIPAA) and Department of Health and Human Services regulations.
I request copies of all health records related to my treatment.
[Note: HIPAA also allows you to request a summary of your medical records. If you prefer a summary, you should agree to a fee beforehand.]
I understand I may be charged a reasonable fee for copying the records, but I will not charged for time spent locating the records. Please mail the requested records to the patient at the above address or directly to Christopher C. Highley D.O. 10627 Professional Cir, Ste. A, Reno, NV 89521.
. I understand that I may be charged for postage.
I look forward to receiving the above records within 30 days as specified under HIPAA. If my request cannot be honored within 30 days, please inform me of this by letter as well as the date I might expect to receive my records*.
*Under HIPAA you can be charged a reasonable fee for copying records. You may also be charged for postage if you ask that records be mailed to you. HIPAA allows 30 days for a provider to respond to your request for records, with one 30-day extension for good reason.