[Company Name] [Street address] [City, ST ZIP Code]	[Contact information for Privacy Official]
HIPAA Privacy Rights Request Form PATIENT INFORMATION
Date
Name (Last, first, middle initial)	Social Security # or Patient ID
Street address, City, ST, ZIP Code
Primary phone number | Other phone number	Email address

Type of Request

Access/copy	Amendment	Restriction
Confidential communication	Accounting of disclosures	Complaint

Please describe nature of action requested (type of information requested; nature of amendment, restriction, alternative communication, or complaint, etc.) in detail.

[Note: If this is an alternative communications request, please list alternative location/address for receiving medical information below.]

Please list [Company Name] staff members that were contacted regarding this matter:

Name	Date
Name	Date
Signature	Date
For Administrative Use Only:
Date received
Action taken
Date
Action taken
Date
Privacy Official signature	Date

Attach additional documentation, if applicable.