Practices in need of a clear, consistent way for patients to apply for a copy of their health record can take advantage of
a free model form issued by the American Health Information Management Association (AHIMA).
The pdf form allows providers to stay compliant with the
2016 interpretive guidance from the HHS Office for Civil Rights (the agency that administers and enforces HIPAA privacy and security rules) on individuals’ right to access their health information. An instruction sheet included with the form summarizes the guidance and includes links to it.
Practices and other providers can tailor the form to their own needs, adding their logo, address or bar code, as they wish.
Make sure to consult state law regarding the fees you can charge for providing copies of patient health information, AHIMA recommends.