Request to Access Protected Health Information PHI - Concentra 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and birthdate in the designated fields. This information is crucial for identifying the correct medical records.
3. Fill in the patient's address to ensure proper delivery of the requested information.
4. Specify the purpose of disclosure and the facility visited, which helps clarify why you are requesting access to these records.
5. Select which records you wish to disclose by checking the appropriate boxes, such as complete medical record or lab results.
6. Provide details about who may receive copies of your records, including their name, address, and preferred method of receiving information (mail, fax, etc.).
7. If applicable, initial next to any sensitive information that may be included in your request.
8. Sign and date the form at the bottom. If a representative is signing on behalf of the patient, include their printed name and explanation of authority.

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