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FORMS

HIPAA

REQUEST FOR ACCESS TO MEDICAL RECORDS

You have the right of access to your medical records. Please use this form to make your request in writing. Our office should respond within 30 days.

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This office shall charge a reasonable fee for our costs of copying and labor, postage (if any), and preparation if applicable.

Thanks for submitting!

Debbie Miles
Administrative Assistant
Nancy Brown
Administrative Assistant
Sherry West
Office Manager
Alexandria Putney
Billing Coordinator
Sheila Shell
Administrative Assistant
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 (937) 276-3356
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(937) 276-9514
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