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Tuolumne Me-Wuk Indian Health CenterTuolumne MeWuk Indian Health Center

Request for Copy of Protected Health Information

YOU HAVE A RIGHT UNDER FEDERAL LAW TO REQUEST A COPY OF YOUR HEALTH INFORMATION.

HOW TO REQUEST A COPY OF YOUR HEALTH INFORMATION:

  1. Complete the Request for Copy of Protected Health Information form
    To prevent possible delays in processing your request, please carefully complete the form including:

    • Your complete address and phone number in case we need to contact you about your request.
    • The date by which you need the records in the section “Date records needed”. For urgent requests, please call 1-209-928-5400.
    • If you are a parent/guardian or personal representative; please include your relationship to the patient in the section “Relationship to Patient” and provide the required documentation.
    • Please clearly state where and how you want the records to be delivered.