HIPAA PHI Request For Access Form

Please complete this form with a completed authorization to disclose protected health information. 

Note: Protected health information provided on portable electronic media or by email will not be encrypted and may be at risk for inadvertent disclosure if it is lost or stolen.

By completing this form, you understand that the HIPAA Privacy Rule sets forth certain types of protected health information that are not subject to a request for access, including, but not limited to, a request for access to psychotherapy notes or a request for access to protected health information when a licensed healthcare provider has determined that access is likely to endanger the life or physical safety of any person. In such a case, LivNao Technologies does not have to grant you access to the requested protected health information and will provide you with notification of the denial, in writing, the reason for the denial, and whether the denial is subject to an appeal.

You also understand that LivNao may impose a reasonable, cost-based fee for providing you with a copy of your protected health information, including (1) labor for copying the protected health information that you requested (whether in paper or electronic form); (2) supplies for creating electronic media.