Name: | DOB: | MRN: | PCP: | Legal Name:

Request to access an adult's record

To request access to another adult's electronic medical record, acting as a ‚Äúpersonal representative‚ÄĚ of the individual as permitted by HIPAA, please complete and submit this request form. Additional information such as the Designation of Personal Representative form may be required and, if so, you will be contacted by a member of the Health Information Services Department. Their record will be accessed through your myD-H account.

Items marked with a red * are required.

Person Making Request:

Your contact information:

Requesting access to adult:

Adult's contact information:

Additional information: