Request Protected Health Information

Under the Health Insurance Portability and Accountability Act, you have a right to inspect and obtain a copy of your health information.  This health information includes medical records and billing records maintained by PsycHealth Ltd.

This right does not apply to:

  • Psychotherapy notes;
  • Information complied in reasonable anticipation of, or for use in a civil, criminal, or administrative action or proceeding; and
  • Protected health information that is:
    • Subject to the Clinical Laboratory Improvements Amendments of 1988, 42 U.S.C. 263a, to the extent the provision of access to you would be prohibited by law; or
    • Exempt from the Clinical Laboratory Improvements Amendments of 1988, pursuant to 42 CFR 493.3(a)(2).

If you are requesting information from a provider please know that this provider will act on this request within 30 days of the date that you submitted this form. The provider will respond within 60 days if the requested information is not maintained or accessible to the provider on-site.  Such action will either inform you of the acceptance of the request and provide you with the requested access; or provide a written denial explaining the reasons for the denial and whether you are entitled to have the denial reviewed.

If the requested information is contained in more than one record set or at more than one location, and access is granted, you will be provided with access to information contained on one of the record sets.

If the provider cannot readily produce the information in the form or format you have requested such information will be made available to you in a readable hard copy form or other form or format agreed to.

Please fill out the following and a PsycHealth staff member will contact you will the next steps for how to obtain your record.

Your Last Name (required)

Your First Name (required)

Your Email (required)

Your Phone Number (required)

If you are requesting information directly from a provider, please fill out the following:

Provider Last Name (required)

Provider First Name (required)

Please describe the information you are requesting:

How would you like to receive this information(hard copy, e-mail, see document on-site, other)?

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