Southern Orthopaedic Specialists
Request for Access to Protected Health Information

Patient:
I, _______________________________________________, request access to my protected health information 
Please print name
contained in the medical records or billing records maintained by Southern Orthopaedic Specialists to review the 

contents and obtain copies. 
or
Patient’s Personal Representative:
I, ______________________________________________, request access to the protected health information of 
Please print name
_______________________________________________ contained in the medical records or billing records maintained 
Please print name
by Southern Orthopaedic Specialists to review the contents and obtain copies.

I have the right to inspect and request copies of whatever portions or the entirety of the health records as well as to 

request a summary explanation of these records. I understand this request will require the collection of these records and 

that Southern Orthopaedic Specialists will arrange a convenient time and place for me to conduct my review of this 

protected health information. I request access and/or copies/summaries of the following information: 

From (date) __________________________ to (date) _____________________________________

From (date) __________________________ to (date) _____________________________________

Please check type of information to be accessed/copied:

__ Other, (specify) _________________________________________________________________________

I would like the protected health information to be provided in (check one):
____ Photocopy format
____ Summary explanation format

And provided to me by the following method (check one):
____ Personal pick-up
____ U.S. Postal Service to (Address)________________________________________________
_____________________________________________________________________________
____ Other, specify: _____________________________________________________________ _____________________________________________________________________________



Signature_________________________________________ Date: ______________________________