Patient Name*

Date of Birth*

Phone Number*

Last Four Digits of SSN#*

Email*

As the patient, or the patient's personal representative, I am requesting a copy of the medical record held by Howard Memorial Hospital*

Date(s) of Service Requested*

Name

I understand the record may include information relating to mental healthcare, communicable diseases, and treatment of alcohol or drug abuse.*

NOTICE: Once your PHI has been disclosed in accordance with this request, it may be re-disclosed to individuals or organizations that are not subject to the HIPAA regulations.

Signature*