PATIENT SORTAL

HIPAA RIGHT OF ACCESS

(THE FUTURE MEMBER SHALL COMPLETE, CHECK, AND SIGN ALL BOXES THAT APPLY)

Pursuant of 45 CFR § 164.524, HIPAA Authority for Right of Access, the undersigned request 

 

 

to release or disclose information related to below reference records/information to Patient Sortal during the period beginning ________________ and ending _________________, for assistance with Continuity of Care during Community Reintegration. According to the Office of Civil Rights, an individual (or that individual’s personal representative) has a right to direct a covered entity to transmit Protected Health Information (PHI) about the individual directly to another person or entity designated by the individual (or personal representative) pursuant to the right of access granted under HIPAA and its implementing regulations.

Thanks for submitting!