Sent
Jan 30, 2026 12:50 PM GMT
(3 months ago)
From
[email protected] (Ashley Dupree)
To
Finalized
User has finalized their signature
Sign Request Finalized Jan 30, 2026 1:29 PM
Revised'12.2021'
PATIENT SORTAL
HIPAA RIGHT OF ACCESS
(THE RETURNING CITIZEN SHALL COMPLETE, CHECK, AND SIGN ALL BOXES THAT APPLY)
Pursuant of 45 CFR § 164.524, HIPAA Authority for Right of Access, the undersigned
request ____________________________________________ to release or disclose
information related to below reference records/information to Patient Sortal during the
period beginning ________________ and ending _________________, for assistance
with Continuity of Care during Community Reintegration. According to the Office of
Civil Rights, an individual (or that individual’s personal representative) has a right to
direct a covered entity to transmit Protected Health Information (PHI) about the
individual directly to another person or entity designated by the individual (or personal
representative) pursuant to the right of access granted under HIPAA and its implementing
regulations.
Patient Information:
Name (print)
Inmate #
Date of Birth
Facility Located
Medical/Dental
Mental Health
Drug & Alcohol Treatment
HIV Information
__________________
Relationship (print)
__________________
Date
__________________
Records/Information to be delivered to:
Patient Sortal
Email (preferred):
Phone: 1-833-PAT1ENT or
1-833-728-1368
Fax: 844-927-5012
_________________________________________________
Name of the individual Giving this Authorization (print)
_________________________________________________
Signature of the individual Giving this Authorization
_________________________________________________
Signature of Witness
Date
HIPAA Authority for Right of Access: 45 CFR § 164.524
(Date of Incarceration)
(30 days before Release Date)
Check all records that apply:
Jacquelynne Grenier
1/30/2026
1/30/2026