724
Main Street,
Prescription
Drug Summary Report Request
(Request for Access to Protected Health Information)
NOTICE:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires
that you be allowed access, with some limited exceptions, to our records
containing your Protected Health Information/Individually Identifiable Health
Information (collectively referred to herein as “PHI”).
For
a printer friendly, Microsoft Word Version, click here
Date
of Request ____________________________________
I,
_________________________________
do hereby request Webb's Family Pharmacy to provide me with a PRESCRIPTION DRUG
SUMMARY REPORT for the following date range:
Starting
Date: _________________
Ending Date: ____________________
I
request that Webb's Family Pharmacy (please
check one):
0 allow me to inspect my PRESCRIPTION
DRUG SUMMARY REPORT at
the pharmacy during normal business hours.
0
make photocopies of my PRESCRIPTION DRUG
SUMMARY REPORT for me to pick up at the pharmacy during normal business hours,
and for which I agree to pay a reasonable, cost-based fee.
0
make photocopies of my PRESCRIPTION DRUG
SUMMARY REPORT and mail to me at the address provided below, and for which I
agree to pay a reasonable,
cost-based fee.
0 I authorize ________________________________ to pick up my
PRESCRIPTION DRUG SUMMARY REPORT.
0
Other:
____________________________________________________________________
(Use this option if you wish to receive your PRESCRIPTION
DRUG SUMMARY REPORT in some other format or by some other manner, such as
electronic mail or fax. Please consult with our Privacy Officer about our
ability to provide your PRESCRIPTION DRUG SUMMARY REPORT in this requested
manner.)
I understand that any use or disclosure of my PRESCRIPTION DRUG SUMMARY
REPORT that I make, whether intentional or unintentional, after reviewing or
obtaining copies of the requested PRESCRIPTION DRUG SUMMARY REPORT is my
responsibility.
_____________________________________________ ________________ _ __________________
Signature
of Person Submitting Request
Date
Telephone Number
Street
Address for Mailing: _____________________________________________________________
City,
State and Zip Code: _____________________________________________________________
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