REQUEST OR PROVIDE RECORDS
(FOR TREATMENT, PAYMENT, OR PATIENT)

ALL FIELDS ARE REQUIRED I am a patient, and I am requesting for records to be sent from the Student Health Center to an outside provider I am a patient, and I am requesting for records to be sent from an outside provider to the Student Health Center I am a patient, and I am requesting a copy of my own records I am a nurse or provider, and I am requesting records for continuity of care
RECIPIENT:	PERSON OR ENTITY TO RECEIVE RECORDS OR REQUEST (This would not be BYU-Idaho Health Center)
FAX NUMBER	CONTACT PHONE NUMBER
MAILING ADDRESS
RECORDS SHOULD BE SENT BY: Mail Fax	TRANSMISSION SHOULD BE ADDRESSED TO:
PATIENT:	PATIENT’S FULL NAME	M F	FORMER/MAIDEN NAME (IF APPLICABLE)
DATE OF BIRTH	I-NUMBER	CONTACT PHONE NUMBER
ADDRESS	TREATING PROVIDER AT THE SHC
HEALTH INFO:	INFORMATION TO BE DISCLOSED Lab Work Radiology Office Visits Private Insurance Form Immunizations Mental Health* Developmental Disabilities* HIV Test Results* Alcohol and/or Drug Abuse* TB Results Other: *State and federal law may govern release of this information. The information may not be fully released.
DATE RANGE OF RECORDS (EXAMPLE: RECORDS FROM JANUARY 2014 – MARCH 2014)
PURPOSE OF DISCLOSURE (EXAMPLES: FOR TREATMENT, FOR MY OWN RECORDS, ETC.)

I am signifying with my signature below that I understand each of the following statements:

If I am a patient requesting my own records, I may be charged a cost-based fee for requests in excess of 10 pages.

The SHC may deny my request as permitted by the Privacy Rule, but will honor the request if required to do so.

I agree to release the SHC from all legal responsibility or liability for release of this information.

SIGNATURE OF PATIENT OR

PERSONAL REPRESENTATIVE: _________________________________________ DATE: ______________

EMPLOYEE REQUESTING RECORDS: ____________________________________ DATE: ______________