REQUEST FOR MENTAL HEALTH RECORDS

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NOTICE

Under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to access your health information, including mental health records. Providers must respond within 30 days (extendable by 30 days with notice). Some information may be excluded or denied under specific circumstances.

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PART I: PATIENT INFORMATION

Section A: Patient Identification

Patient Full Legal Name: ___________________________________

Other Names Used (maiden, alias, etc.): ____________________

Date of Birth: ____________________________________________

Social Security Number (last 4 digits): ____________________

Patient ID/Medical Record Number (if known): _______________

Current Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Email: ____________________________________________________

Section B: Patient Status

☐ I am the patient requesting my own records

☐ I am the legal representative of the patient (complete Section C)

Section C: Legal Representative Information (if applicable)

Representative Name: _______________________________________

Relationship to Patient: ___________________________________

Legal Authority (check one):

☐ Parent of minor child (under 18)

☐ Legal guardian
Court that appointed: ______________________________________
Date of appointment: _______________________________________

☐ Healthcare agent/power of attorney
Date of POA: _______________________________________________

☐ Personal representative of deceased patient
Date of death: _____________________________________________
Authority: _________________________________________________

☐ Other legal authority: ______________________________________

Attach documentation of legal authority

Representative Address:
_______________________________________________________________
_______________________________________________________________

Representative Phone: _____________________________________

Representative Email: _____________________________________

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PART II: PROVIDER/FACILITY INFORMATION

Provider/Facility Name: ____________________________________

Department (if applicable): ________________________________

Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Fax: ______________________________________________________

Provider's Privacy Officer/Medical Records Department:
_______________________________________________________________

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PART III: RECORDS REQUESTED

Section A: Types of Records

I request access to the following records (check all that apply):

Clinical Records:

☐ Complete mental health treatment record

☐ Psychiatric evaluation(s) and assessment(s)

☐ Psychological testing results and reports

☐ Treatment plans

☐ Progress notes/session notes

☐ Discharge summary(ies)

☐ Hospital admission and discharge records

☐ Emergency room records

☐ Consultation reports

Medication Records:

☐ Medication history/prescription records

☐ Medication administration records (MAR)

☐ Lab results related to medication monitoring

Other Records:

☐ Diagnosis/diagnostic codes

☐ Billing records and itemized statements

☐ Insurance correspondence

☐ Correspondence regarding my care

☐ Appointment history

☐ Other (specify): ___________________________________________

Section B: Specially Protected Records

I understand the following records have special protections and am specifically requesting:

☐ Psychotherapy Notes
Note: Psychotherapy notes are maintained separately and may be denied. These are the therapist's personal notes analyzing sessions - not regular progress notes.

☐ Substance Use Disorder (SUD) Treatment Records
Note: Protected under 42 CFR Part 2. A specific authorization may be required.

☐ HIV/AIDS Information

☐ Genetic Testing Information

☐ Records Regarding Minors' Confidential Treatment

Section C: Time Period

I request records from the following time period:

☐ From: _______________________ To: ___________________________

☐ All records on file

☐ Most recent _______ months/years

☐ Specific dates of service: __________________________________

☐ Records related to specific treatment/hospitalization: ________
___________________________________________________________

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PART IV: FORMAT AND DELIVERY

Section A: Preferred Format

I request my records in the following format:

☐ Paper copies

☐ Electronic copies via:
☐ Secure email to: _________________________________________
☐ Patient portal
☐ CD/USB drive
☐ Electronic health record system (specify): _________________

☐ No preference - provider's standard format

Note: Under the 21st Century Cures Act and HIPAA, providers must provide records in the format you request if readily producible in that format, or in a readable alternative.

Section B: Delivery Method

I request my records be delivered by:

☐ Mail to the address provided in Part I

☐ Secure email to: ___________________________________________

☐ Pick up in person (ID required)
Preferred location: ________________________________________

☐ Patient portal access

☐ Fax to: ____________________________________________________
(Note: Fax may not be secure)

☐ Deliver to third party (complete Part V)

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PART V: THIRD PARTY RECIPIENT (if applicable)

If you want records sent directly to a third party, complete this section:

☐ I request that copies of my records be sent to the following:

Recipient Name: ___________________________________________

Organization (if applicable): ______________________________

Address:
_______________________________________________________________
_______________________________________________________________

Phone: ____________________________________________________

Fax: ______________________________________________________

Email: ____________________________________________________

Purpose of Disclosure:

☐ Continuity of care/new provider

☐ Legal matter

☐ Disability determination

☐ Insurance

☐ Personal

☐ Other: _____________________________________________________

Note: This section constitutes an authorization to release records to the third party. More specific authorization may be required for certain record types.

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PART VI: FEES AND COSTS

Section A: Acknowledgment of Potential Fees

☐ I understand that the provider may charge a reasonable, cost-based fee for copying my records

☐ I understand that fees vary by state and format requested

☐ I request an estimate of fees before the records are prepared

☐ I authorize fees up to $_________ without additional approval

Section B: Fee Waiver Request (if applicable)

☐ I request a fee waiver or reduction because:

☐ I am indigent/unable to pay

☐ Records are needed for government benefits application

☐ Records are needed for legal matter involving my rights

☐ Other hardship: ____________________________________________

Supporting information:
_______________________________________________________________
_______________________________________________________________

Section C: State Fee Limitations

Note: Many states limit the fees that can be charged for medical records. Common provisions include:

• HIPAA: Limits fees to reasonable, cost-based amount for labor, supplies, and postage
• California: Specific per-page limits; free for Medi-Cal recipients in some circumstances
• Texas: Regulated per-page fees
• Florida: Statutory limits on copy charges
• New York: Reasonable fee limits

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PART VII: EXPEDITED PROCESSING REQUEST (if applicable)

☐ I request expedited processing of this request because:

Reason for urgency:
_______________________________________________________________
_______________________________________________________________

Deadline (if any): ________________________________________

Documentation attached: ☐ Yes ☐ No

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PART VIII: STATE-SPECIFIC INFORMATION

California

Applicable Law: California Civil Code sections 56.10-56.11; Health & Safety Code section 123110

Timeline: 15 days from receipt of request (can be extended by 30 days)

Special Provisions:
- Patient may request amendment of records
- Mental health records generally accessible with some exceptions
- Psychotherapy notes may be withheld if disclosure would be harmful

Fee Limits: Reasonable clerical costs plus $0.25/page or $0.50/page for microfilm

Texas

Applicable Law: Texas Health & Safety Code Chapter 611; Occupations Code Chapter 159

Timeline: 15 days (written records); 30 days (other)

Special Provisions:
- Patient has right to access mental health records
- Access may be denied if licensed professional determines disclosure would be harmful
- Patient may request review by another professional if access denied

Fee Limits: Regulated fees; first 10 pages may be free in some circumstances

Florida

Applicable Law: Florida Statutes section 395.3025; section 456.057

Timeline: Within a reasonable time (typically 30 days)

Special Provisions:
- Patient has right to access their health records
- Limited exceptions for mental health records that could be harmful

Fee Limits: Statutory limits apply

New York

Applicable Law: Public Health Law section 18; Mental Hygiene Law Article 33

Timeline: 10 days to acknowledge; records within 30 days

Special Provisions:
- Qualified persons may access mental health records
- Access may be denied if disclosure would cause substantial and identifiable harm
- Patient may request review by records access review committee

Fee Limits: Reasonable fee not exceeding costs

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PART IX: SIGNATURE AND VERIFICATION

Section A: Patient/Representative Certification

I certify that:

☐ I am the patient named above, OR I am the legal representative with authority to access these records

☐ The information provided is true and accurate

☐ I understand this request may be subject to verification of identity

☐ I understand I may be charged a reasonable fee for copies

☐ I understand the provider has up to 30 days to respond (with possible 30-day extension)

Signature: ________________________________________________

Print Name: _______________________________________________

Date: _____________________________________________________

Section B: Identification Verification

For in-person requests or if required by provider:

☐ Driver's license/State ID #: ________________________________

☐ Other government-issued ID: _________________________________

☐ Other form of verification: _________________________________

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PART X: PROVIDER RESPONSE SECTION (For Provider Use)

Section A: Receipt of Request

Date Received: ____________________________________________

Received By: ______________________________________________

Identity Verified By: _____________________________________

30-Day Deadline: __________________________________________

Extension Deadline (if applicable): ________________________

Section B: Response

Date of Response: _________________________________________

☐ Request Granted in Full
Records provided on: _______________________________________
Format: ____________________________________________________
Fee charged: $______________________________________________

☐ Request Granted in Part
Records provided: __________________________________________
Records withheld: __________________________________________
Reason for partial denial: __________________________________

☐ Request Denied
Reason: ____________________________________________________
___________________________________________________________

☐ Extension Needed
Reason: ____________________________________________________
New deadline: ______________________________________________
Patient notified on: _______________________________________

Section C: Denial/Partial Denial Information (if applicable)

If request is denied in whole or part, patient must be informed of:

☐ Right to written explanation of denial

☐ Right to request review of denial (for certain denials)

☐ Right to file complaint with HHS Office for Civil Rights

☐ Identity of reviewing official (if applicable)

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PART XI: APPEAL OF DENIAL

If your request is denied, you may have rights to appeal:

Section A: Request for Review

☐ I request review of the denial of access to my records

Records denied: ___________________________________________

Reason given for denial: __________________________________

Why I believe I should have access:
_______________________________________________________________
_______________________________________________________________

Signature: ________________________________________________

Date: _____________________________________________________

Section B: Complaint to HHS Office for Civil Rights

If you believe your HIPAA rights have been violated, you may file a complaint with:

U.S. Department of Health and Human Services
Office for Civil Rights
Website: https://www.hhs.gov/ocr/complaints/
Phone: 1-800-368-1019

Complaints must generally be filed within 180 days of the violation.

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PART XII: REQUEST FOR AMENDMENT OF RECORDS

If you believe your records contain errors:

☐ I request amendment of the following information in my records:

Specific information to be amended:
_______________________________________________________________
_______________________________________________________________

Requested correction:
_______________________________________________________________
_______________________________________________________________

Reason for requested amendment:
_______________________________________________________________
_______________________________________________________________

Supporting documentation attached: ☐ Yes ☐ No

Note: Providers must respond within 60 days. They may deny amendment but must allow you to submit a statement of disagreement.

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IMPORTANT INFORMATION

Your Rights Under HIPAA

• Right to Access: You have the right to inspect and obtain copies of your health information
• Timeline: Providers must respond within 30 days (extendable once by 30 days with notice)
• Format: You can request records in electronic format if maintained electronically
• Fees: Limited to reasonable, cost-based fees
• Denial: Can only be denied for specific reasons; some denials are reviewable

Records That May Be Withheld

Under HIPAA and state law, providers may withhold:

1. Psychotherapy Notes: Providers are not required to provide psychotherapy notes (notes kept separately analyzing session content)

2. Harm Exception: Information that a licensed professional determines would endanger the life or safety of the patient or another person

3. Information About Others: Information that would identify another person (unless that person is a healthcare provider)

4. Legal Restrictions: Records compiled for civil, criminal, or administrative proceedings

21st Century Cures Act

The Information Blocking Rule prohibits healthcare providers from engaging in practices that interfere with access to electronic health information. This strengthens your right to access your records electronically.

42 CFR Part 2 (SUD Records)

If you received treatment for a substance use disorder at a federally assisted program, additional protections apply. These records generally cannot be redisclosed without specific consent.

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RESOURCES

HHS Office for Civil Rights (HIPAA)
Website: https://www.hhs.gov/hipaa/
Phone: 1-800-368-1019

State Health Department (for state-specific questions)

Patient Advocate Foundation
Website: https://www.patientadvocate.org/

Health Information Rights
Website: https://www.healthit.gov/topic/your-health-data

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TRACKING YOUR REQUEST

Date	Action	Response
__________	Request submitted
__________	Acknowledgment received
__________	Fee estimate received
__________	Fee paid	$__________
__________	Records received	☐ Complete ☐ Partial
__________	Appeal filed (if needed)
__________

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NOTES:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

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Keep a copy of this request and all correspondence. If you do not receive a response within 30 days, follow up with the provider's medical records department. If your rights under HIPAA are violated, you may file a complaint with the HHS Office for Civil Rights.