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

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  • AUTHORIZATION

    By typing your name below, you as a patient or patient representative authorize this request.

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

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