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AKDHC > Patients > Patient Forms

Patient Forms

For your convenience, common forms that you may need when you come to our office are listed below.

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Not Sure What Form You Need?

Requesting copies of your health information
You or your authorized representatives may request copies of your AKDHC health information.  All requests will be reviewed and responded to within 30 days of receiving your written request.  Click on the below link to view and print the Request for Medical Records form.
Request for Medical Records

Authorization to disclose your health information
We may use and disclose your health information without your authorization for treatment, payment and health care operations, as well as other specific circumstances described in our Notice of Privacy Practices.  For other disclosures, we are required to obtain your written authorization to release your health information.  For example, if you would like us to share your health information with a family member or friend.  Click on the below link to view and print the Authorization for Release of PHI form.
Authorization for Release of PHI
You have the right to revoke an existing authorization.  Click on the below link to view and print the Authorization for Release of PHI Revocation form.
Authorization for Release of PHI Revocation

Restrictions
You have the right to identify a specific person or entity that you do not want to have access to your health information.  Click on the below link to view and print the Restriction Request form.
Restriction Request
If you feel that a requested restriction in your record is no longer necessary you can revoke the restriction.  Click the below link to view and print the Restriction Revocation form.  
Restriction Revocation

Amendment Requests
If you identify something in your medical record that you feel is inaccurate or incomplete you have the right to submit a request for an amendment.  Requests will be reviewed by your physician and a response will be provided to you within 60 days of receiving the request. Click on the below link to view and print the Amendment Request form.
Request for PHI Amendment

Request for Accounting of Disclosures
Certain disclosures of your health information are tracked in an Accounting of Disclosures log. You may request that we produce this log for you that contains disclosures made within 6 years of your request. Disclosures not included in this log are ones made for treatment, payment, healthcare operations, and those disclosures made with your authorization.   Click on the below link to view and print the Request for Accounting of Disclosures form.
Request for Accounting of Disclosures

Confidential Communications
There are times when a patient may feel that their safety would be at risk if someone at their home were aware that they were seeking treatment at our facility.  We can communicate directly with you through personal mobile phone and email accounts.  If you would like to request additional protection by having all mail sent to a different mailing address and direction to not contact you at your home number we can accommodate all reasonable requests.  Click on the links below to view and print the forms:

Confidential Communication Request form
Confidential Communications Revocation

Privacy Complaint
If you feel that we have violated your privacy by using or disclosing your health information in a way not allowed by HIPAA you have the right to make a formal complaint.  Click on the below link to view and print the Privacy Complaint form.
Privacy Complaint

 

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