Patient Audit Trail Request Form

Patient Audit Trail Request Form

Please complete the following form to request a copy of the audit trail for your medical record. The Audit Trail report provides a summary of personnel and providers who have accessed your record within the last six (6) months. The Audit Trail includes the name, role, department, and date of access.

Once a Patient Audit Trail Request has been received, Sansum Clinic's Release of Information (ROI) department will process the request and deliver the report in the format selected below.

If you have questions or concerns about an individual's access to your record, please contact Sansum Clinic's Compliance & Privacy Officer, Mara Sorkin at 805-681-1719 or msorkin@sansumclinic.org.

Patient Name*

Please include the full legal name (First Middle Last) for the patient whose audit trail is being requested.

Patient Date of Birth*

Please include the birth date for the patient whose audit trail is being requested.

Reason for Audit Trail Request

Please help us understand why you are requesting a copy of the patient audit trail.

I am interested to see who has accessed my record recently.

I have a privacy concern related to unauthorized access to my record.

I require a copy of my audit trail record for legal purposes.

Other

What is Your Preferred Format for Receiving the Patient Audit Trail?*

Select or enter value

What is Your Preferred Method of Communication Regarding This Request?*

Release of Information (ROI) or Compliance/Privacy personnel may contact you with questions or concerns about fulfilling your audit trail request. Please select your preferred method(s) of contact for this request.

Your current phone number or mailing address listed in your patient record will be used to contact you. If you need to update your current information, please contact the MyChart Help Desk at (805) 898-3333 Monday-Friday from 8:00AM-5:00PM.

MyChart Message

Phone Call

Letter By Mail

Name of Person Requesting Audit Trail*

Please enter your full name (First Middle Last) here.

Requester Relationship to Patient*

If you are the patient, please indicate "Self."

If you are not the patient, please indicate your relationship to the patient (i.e. Parent/Guardian, Court-Appointed Guardian, etc.). NOTE: Only authorized representatives may submit a patient audit trail request. If you are not authorized to request PHI on behalf of the patient, the Release of Information (ROI) department may deny your request.

Additional Comments

You may submit any additional questions or clarifying information about your request here.

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