Right to Access

To Receive Your Medication Expenditures:
Your must fill out the Right to Access and Consent for Release of Protected Health Information Form

POLICY: In the case of a verbal or written request for PHI included in the Pharmacy’s Medical Expense and Accounts Receivable Information, the Pharmacy may (at the discretion of the Pharmacist, Privacy Officer, bookkeeper or person receiving a written or verbal request) release patient specific information limited to as included in it’s then current Medical Expense and/or Accounts Receivable Information directly to the patient or authorized agent of the patient without having the release herein previously completed.

PURPOSE: In any case where the requested information goes beyond the Pharmacy’s then current Medical Expense and/or Accounts Receivable Information or a Pharmacy employee believes the patient’s PHI is best protected by having the release herein completed prior to release of any PHI, this release serves as the documented request for the release of Protected Health Information (PHI) to the patient or authorized agent of the patient as designated below.

Click below for printable PDF
(Fill in and fax back 715-823-6000)

Click below for printable Word DOC
(Fill in and fax back 715-823-6000)

 

 *Fax completed release form to (715) 823-6000
*Mail your completed release form to:

Erickson Pharmacy
Attn: Insurance/Billing
 8 S. Main S.
Clintonville, WI 54929

PHARMACY: (715) 823-2222
PHARMACY FAX: (715) 823-6000

Right to Access and Consent for Release of Protected Health Information (PHI) Online Form

[contact-form][contact-field label=’First Name’ type=’firstname’ required=’1’/][contact-field label=’Last Name’ type=’lastname’ required=’1’/]Name For Whom PHI is Needed *
[contact-field label=’First Name’ type=’text’ required=’1’/][contact-field label=’Last Name’ type=’text’ required=’1’/]DOB For Whom PHI is Needed *
[contact-field label=’Date of Birth’ type=’text’ required=’1’/]
I am requesting the following PHI (check only those that apply): *
[contact-field label=’PRESCRIPTION MEDICATION ACTIVITY INFORMATION’ type=’checkbox’/][contact-field label=’PRESCRIPTION EQUIPMENT or DEVICE ACTIVITY INFORMATION’ type=’checkbox’/][contact-field label=’PATIENT DEMOGRAPHIC INFORMATION’ type=’checkbox’/][contact-field label=’BOOKKEEPING/ACCOUNTING ACTIVITY INFORMATION’ type=’checkbox’/][contact-field label=’CURRENT INSURANCE INFORMATION (FOR THE DATE OF REQUEST)’ type=’checkbox’/][contact-field label=’OTHER’ type=’checkbox’/][contact-field label=’If you checked other: SPECIFIC DETAIL REQUIRED*’ type=’textarea’/][contact-field label=’My relationship with whom the PHI is being requested is: *’ type=’text’ required=’1’/]
A unique copy of this release must be completed for any given 12 month period. The specific time period for which records are being requested (no future dating allowed) is: (TIME PERIOD TO TIME PERIOD) *
[contact-field label=’Time Period to Time Period’ type=’ text’ required=’1’/][contact-field label=’This disclosure is being made for the purpose(s) of: ‘ type=’textarea’ required=’1’/][contact-field label=’How would you like to receive the Release of your PHI? *‘ type=’select’ required=’1′ options=’Printed & Mailed,Faxed,I will pick up at the Pharmacy’/][contact-field label=’Address (Must match requesting person above): *‘ type=’text’/][contact-field label=’Line 1′ type=’text’/][contact-field label=’Line 2′ type=’text’/][contact-field label=’City’ type=’text’/][contact-field label=’State’ type=’text’/][contact-field label=’Zip Code’ type=’text’/]
If you want your records faxed, what fax number should we use? *
[contact-field label=’My Fax Number’ type=’text’/]
I certify the records being requested are my own personal records or I have the patient’s authorization to request these records. I certify the records obtained are done so in good moral character and without malicious intent. You are required to enter a digital signature which will be binding as your actual signature. Your electronic signature below indicates all information provided is true, complete, and correct. By typing my name in the following box, I certify that I have read, fully understand, and accept all terms of the PHI disclosure statement: *
[contact-field label=’Electronic Signature’ type=’text’ required=’1’/][contact-field label=’Date’ type=’text’ required=’1’/][contact-field label=’Date of Birth of Signer: *‘ type=’text’ required=’1’/]
[contact-field label=’Contact Phone Number *‘ type=’text’ required=’1’/][/contact-form]

Your request for information will be completed within 30 days. This form must be completed in its entirety and submitted to Erickson Pharmacy to begin processing information. Failure to submit this form will result in your request not being processed. Thank you for your patience.