Request for Protected Health Information

Please fill out this form completely. Incomplete Forms will not be processed.

Asterisks (*) indicate a required field.

HIPAA Request for PHI Form

Complete this form to make a request for an electronic or paper copy of your protected health information ("PHI") as under the Health Insurance Portability and Accontability Act ("HIPAA"). You can complete this form on your own behalf of as the legal representative of the patient. If you are the patient's representative, you will be asked to provide information validating your authority to request PHI on behalf of the patient.


You can access Adaptive's Notice of Privacy Practices for more information about your rights under HIPAA and how Adaptive may use or disclose your PHI. If you have any questions, including about this form, please contact the Adaptive Privacy Office at privacy@adaptivebiotech.com.


Please fill this form out in its entirety. Incomplete forms will not be processed.


Use of this web form requires an email. If you do not want to provide your email, please use any of the alternative request methods rather than this form as outlined in our Notice of Privacy Practices.

MM/DD/YYYY

(Optional) Diagnostic Number of the Report, including this information may help us find your records more quickly

(Optional) Including this information may help us find your records more quickly


Information Requested

Under HIPAA, you have the right to access the PHI Adaptive maintains about you in a Designated Record Set. A “Designated Record Set” is a group of records that comprises, among other things, the records used, in whole or in part, by or for the covered entity to make decisions about individuals.

I am requesting (select one)*

In case you are unsure of what to request, please tell us more about the specific PHI you are requesting...


Form and Format

How would you like Adaptive to provide your records?

Requested Format

If different than the email input in the 'Patient Information' section, please provide below

If different than the address input in the 'Patient Information' section, please provide below

Please specify which format you would like your records provided in


Requestor Information

We would like to know more information about who is requesting the patient's information.


If you are making this request as the patient's representative, we will need evidence demonstrating that you have the legal authority to make the request on the patient's behalf. We will be contacting you at the address you've provided to confirm that you have the legal authority to make the request on the patient's behalf. You can also provide documentation establishing your legal authority to request PHI on behalf of the patient by emailing privacy@adaptivebiotech.com.

Select
Caret IconCaret symbol

Questions?

You can ask questions about this form by contacting us either by email at privacy@adaptivebiotech.com or by mail at the address listed below:


Adaptive Biotechnologies

Attn: HIPAA Privacy Officer

Adaptive Legal Department

1165 Eastlake Avenue E

Seattle, Washington 98109