Request for Access to PHI

Complete this form to request access to the Protected Health Information (PHI) that has been created or is maintained by Vail Communities. Once you have completed this request form, we will send the official Request for Access to Protected Health Information to your email address or text it to your phone number below through DocuSign for your signature.

Full Legal Name

Date of Birth

Email Address:

Phone Number

How would you like to receive the form to sign?

Email address listed above

Text through phone number listed above

Address

City

State

Zip Code

Time Period of Request

What is the date range of the records you are requesting? If you do not specify a date range we will provide records for one year from the date of your request.

Requesting access to the following records

Check whichever ones apply

Treatment or Goal Plans

Clinical assessment or records

Diagnostic Assessments or other records documenting eligibility for Vail Communities services

Authorization to Release Information Forms

Information recorded in the Client Profile

Progress notes or records documenting services provided by Vail Communities employees

Progress notes or records received from other providers

All records

Other (describe)

Location to Send the Information

If you are not the client, please indicate your capacity or authority to sign on their behalf

Guardian

Other legal representative (describe below)

Thank you!

We will respond to your request promptly. Please contact records@vailplace.org if you have any questions.

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