Medical Record Privacy Forms

Authorization to Disclose Protected Health Information

This form may be used to authorize FPCA to release your full medical record or a portion of the record to another physician, insurance company,or for personal use, etc.

Authorization to Request Protected Health Information from Other Healthcare Providers

This form may be used to request medical records to be sent from your former primary care provider or a specialist to FPCA.

Notice of Privacy Practices

This document is a downloadable version of FPCA’s official Notice of Privacy Practices in PDF format. Updated 2013.

Patient Privacy Complaint Form

This form may be used to formally file a complaint with the FPCA Privacy Contact, if you feel there has been a violation of your HIPAA privacy rights.

Phone and Message Authorization for Protected Health Information

This form may be used to grant FPCA authorization to leave messages with family members or anyone you designate or on your answering machine, regarding test results, appointments, etc.

Request for Correction/Amendment of Protected Health Information

This form may be used to request a correction or amendment of any portion of your medical record created by FPCA. Please note that any request is subject to the approval of your FPCA physician.

Request to Inspect and Copy Protected Health Information

This form may be used to request a time to inspect your complete FPCA medical record. Please note that this will be a scheduled time apart from an office visit, during normal business hours.

Requests for Limitations and Restrictions of Protected Health Information

This form may be used to request limitations and restrictions be placed on your protected health information. Please note that FPCA must approve these restrictions and that they may not interfere with FPCA’s submission of claims to your insurance plan for payment.