DOEA Form 184 "Access to Records Request for Inspection of Protected Health Information (Phi)" - Florida

What Is DOEA Form 184?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA Form 184 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 184 "Access to Records Request for Inspection of Protected Health Information (Phi)" - Florida

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Access to Records Request for Inspection of Protected Health Information
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
REQUEST SECTION
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA)
you have a right to request the opportunity to inspect and copy health information that
pertains to you. The Department of Elder Affairs will evaluate your request and will either
grant it or explain the reason why the request will not be granted. In the event that your
inspection request is not granted you may request that the decision be reviewed by
someone other than the person who originally denied the request.
I, (Client Name) ________________________ hereby request to inspect the following health
information pertaining to me maintained at the Department of Elder Affairs):
_______________________________ _______________________________
Signature of Patient
Date
DOEA Form 184 (04/03)
Page 1 of 3
Access to Records Request for Inspection of Protected Health Information
Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
REQUEST SECTION
As required by the Health Information Portability and Accountability Act of 1996 (HIPAA)
you have a right to request the opportunity to inspect and copy health information that
pertains to you. The Department of Elder Affairs will evaluate your request and will either
grant it or explain the reason why the request will not be granted. In the event that your
inspection request is not granted you may request that the decision be reviewed by
someone other than the person who originally denied the request.
I, (Client Name) ________________________ hereby request to inspect the following health
information pertaining to me maintained at the Department of Elder Affairs):
_______________________________ _______________________________
Signature of Patient
Date
DOEA Form 184 (04/03)
Page 1 of 3
Access to Records Request for Inspection of Protected Health Information
REVIEW SECTION INTERNAL USE ONLY
This section is to be completed by the reviewer:
Date received:
Reviewed by:
Chief Privacy Officer:
Review Date:
The inspection request is hereby:
Granted ____
Denied ____
If the request is denied, indicate the reason for the denial:
Reviewer’s Comments:
_______________________________ _______________________________
Signature
Date
DOEA Form 184 (04/03)
Page 2 of 3
Access to Records Request for Inspection of Protected Health Information
REVIEW SECTION
This section is to be completed by the reviewer:
Date received:
Reviewed by:
Chief Privacy Officer:
Review Date:
Reviewer’s Decision:
Grant the Inspection Request ___
Deny the Inspection Request
___
Reviewer’s Comments:
_______________________________ _______________________________
Signature
Date
DOEA Form 184 (04/03)
Page 3 of 3
Page of 3