RECORDS REQUEST:
You have the right to request a copy of your medical record. This request must be in writing and I must respond to your request within 15 business days. There are specific limitations that may allow me to deny a request for records. If I do deny a request, in most cases, I must inform you of my decision to deny and you may have the right of appeal in some situations.
To request your record, you must submit a written request that includes your name (or the name of the minor if you are the parent or legal guardian) date of birth, date of the request, the dates that the request covers, the specific information you would like released (for example, “I would like a complete record of all dates of service” or “I would like a list of billing and payments for the year of 2020.”), and any specific exclusions to the records. In addition to the completed form, I may contact you for more information in order to meet the specifics of your request.