HIPAA Compliance/Patient Request for Health Info

Patient Request for Health Info

EPI is governed by the Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. §1301 et seq.). Such use of your personal medical information and history shall be protected in compliance with HIPAA.

If you would like to request a copy of your personal data, please complete the web form below.

Patient Request for Health Info

Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How would you like to receive your records?*
- Mail
- Email
- Fax
EPI should provide records to:*
- Myself
- Personal Representation (indicated below)
Recipient Name
Recipient Phone
Recipient Fax
Recipient Mailing Address
Recipient Email (if applicable)
AUTHORIZATION
By typing your name below, you as a patient or patient representative authorize this request.
Name of Patient or Patient Representative*
Relationship
Date*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.