1. I hereby request that the Provider named above and its Business Associates, provide me with the following protected health information (“PHI”), to the extent contained in any of Provider’s (or Business Associate’s) Designated Record Sets (as defined by HIPAA) (the “Requested Files”).
The PHI I request includes all written Care Plans (also called Plans of Care, Treatment Plans, Discharge Summaries, Continuity of Care Plans, Encounter Notes, Patient Summary), and all X-Rays/Radiographs created for me in (the month/year after this request).
2. I hereby request that the Provider prepare all Requested Files so as to include all original contents exactly as stored in the Provider’s on-site or archived paper or electronic health record systems and, if applicable, exactly as submitted for reimbursement to public or private health insurance plans.
3. I hereby request that the Provider format Requested Files in pdf file format for Care Plans and jpg or png file format for x-rays/radiographs.