Request for Access to Records DHS 2093 11/11
|[pic] |SHARED SERVICES |[pic] |
| |Information Security and Privacy Office | |
Request for Access to Records
For use by Department of Human Services (DHS) and Oregon Health Authority (OHA) clients requesting access to their own records.
|Client name (print): |ID number (case, prime, reservation number or SSN): |
| | |
|Client’s mailing address: |
| |
|Client’s phone number (optional): |Client’s email address (optional): |
| | |
|Record holder (office, district, program): |Date of birth: |
| | |
|Location of record (address): |Date of request: |
| | |
Submit this request to the office where services were received.
Are you requesting: To review the file To receive copies
▪ DHS and OHA cannot give you access to psychotherapy notes.
▪ DHS and OHA cannot give you access to information that is no longer available.
▪ DHS and OHA may not be able to provide access to some records or information.
▪ If DHS or OHA denies all or a portion of your request, you have a right to request a review.
▪ You may be charged a fee for copying your records.
|Please specify the type of record or information and the dates you are requesting: |
| |
| |
|Full legal signature of individual or authorized personal representative: |Date: |
| | |
|Personal representative authentication: |Relationship to client: |
| | |
|DHS or OHA staff only. Approved Denied Delayed |
|If delayed we will act on your request by: | | |
|Reason for delay or denial: | |
| | |
| |
| | | | | |
|(DHS or OHA representative signature) | |(Date) |
Your right to access your information
You have a right to request access to or copies of information about yourself that is in
DHS or OHA records.
▪ You have a right to have an answer to your request within 30 days if the information is at this location. If the information is not at this location, you have the right to have an answer within 60 days. If there are delays in getting you the answer, you will be notified and this delay cannot be more than an additional 30 days. In the case of written accounts under ORS 179.505, the records must be disclosed within five (5) calendar days, unless the request falls within one of the exceptions.
▪ You may be charged a fee.
▪ Your request may be denied if professionals involved in your case believe that access to your information could be harmful to you or others. You will receive an answer in writing.
▪ You have the right to request a review of a denial. DHS or OHA will make a decision within a reasonable time. You will get an answer in writing. The answer will include the reason
for the decision.
You have a right to file a complaint if you disagree with the decision. Complaints may be directed to any of the following:
State of Oregon Department of Human Services
Governor’s Advocacy Office, 500 Summer St. NE, E17, Salem, Oregon 97301-1097
Phone: 1-800-442-5238, Fax: 503-378-6532, Email: @state.or.us
Oregon Health Authority, Privacy Officer
500 Summer Street NE, E24, Salem, OR 97301
Phone: 503-945-5780, Fax: 503-947-5396, Email: DHS.PrivacyHelp@state.or.us
U.S. Department of Health and Human Services, Office for Civil Rights
(for health information only)
Medical Privacy, Complaint Division, 200 Independence Avenue, SW HHH Building, Room 509H, Washington, D.C. 20201
Phone: 866-627-7748, TTY: 886-788-4989, Email: ocrcomplaint@
For current or former patients of the Oregon State Hospital (OSH) or Blue Mountain Recovery Center (BMRC):
|OSH – Director of Consumer and Family Services |BMRC – Superintendent |
|2600 Center St. NE, Salem, OR 97301 |2600 Westgate, Pendleton, OR 97801 |
|Phone: 503-945-7132 |Phone: 541-276-0810 extension: 236 |
|This document can be provided upon request in alternative formats for individuals with disabilities or in a language other than English for people with limited English |
|skills. To request this form in another format or language, contact your local office. For a list of local offices please see DHS/localoffices/index.shtml. |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.