Records Request

Client Name(Required)

Date of Request(Required)

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, am requesting copies of the following records from Team Recovery Ohio, LLC.:

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Reason for Request(Required)

Per Team Recovery Ohio, LLC. Policy and in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2, all requests for records must be done in writing. Team Recovery Ohio, LLC. has 72 hours to respond to the request. If in the opinion of the Clinical Director, information from clinical/medical record is medically contraindicated, a verbal denial will be offered using, and in compliance with HIPAA. By typing my name below, I affirm that I am the individual identified in this request and that I am legally authorized to request these records. I acknowledge that my typed name serves as my electronic signature and is legally binding.

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Max. file size: 50 MB.

If records are requested by an individual other than the named individual, state reason for the request:

All records will be sent via email unless otherwise requested

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Records Request

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