Patient rights

Request access to your records

You have a right under HIPAA to see and receive a copy of the protected health information Servants Mission holds about you. Submit your request below; Compliance reviews every entry and delivers records within 30 calendar days.

Awaiting counsel review

Notice for requesters

The agency's formal access-request notice — identity-verification step language, designee handling under HIPAA Section 164.502(g), and the cost-based fee schedule under Section 164.524(c)(4) — is awaiting counsel sign-off. Submit your request anyway. Compliance reviews every entry within five business days, contacts you to verify identity through the channel you provided, and delivers records within 30 calendar days. One 30-day extension is allowed if you are notified before the original deadline. The formal notice will replace this placeholder once counsel has signed off.

Source: _docs/HIPAA_OPERATIONS_BLUEPRINT.md → Gate 3

Don't include health details in this form

Don't include diagnoses, medications, or treatment details in the description. Describe what records you're looking for in general terms (for example, "visit notes from January through March"). Compliance follows up to gather any further details under the appropriate authorization.

Your contact details

Required so Compliance can contact you for identity verification. We never release records until identity is confirmed.

Your full name

Used to match against authorizations on file.

Your email

Primary contact channel for identity verification.

Who are the records about?

If you are not the patient, choose the matching relationship. Compliance verifies authorization is on file before release per HIPAA Section 164.502(g).

Your relationship to the patient

Determines whether designee authorization handling applies.

Date range (optional)

Narrow the records request to a specific date range, or leave blank for all available records.

From

How would you like to receive the records?

Encrypted email — Compliance sends an encrypted PDF to a delivery email address you specify.Paper mail — Records mailed to a postal address. Reasonable cost-based fees may apply per HIPAA Section 164.524(c)(4).In-person pickup — Compliance contacts you to schedule a pickup at the agency office.

Delivery email

Leave blank to use the same email as your contact email above.

Description of records requested (optional)

If you're looking for specific records, describe them in general terms here. Don't include health details — describe what you're looking for in general terms (for example, "visit notes from January through March"). Up to 2000 characters.

What happens next?

Compliance reviews every request within five business days.
We contact you to verify your identity through the channel you provided. Records are not released until identity is confirmed.
Records are delivered within 30 calendar days per HIPAA Section 164.524. One 30-day extension is allowed if you are notified before the original deadline.

Requesting on behalf of someone else?

If you are a parent of a minor, legal guardian, or hold power of attorney for the patient, choose the matching relationship in the form. Compliance will check that an authorization is on file before releasing records, per HIPAA Section 164.502(g). If no authorization is on file, we will contact you to complete one.

Have a privacy concern instead?

If you believe the agency mishandled your information, file a privacy concern at /patient-rights/privacy-concern. That path is separate from records-access requests and can be submitted anonymously.

Notice for requesters

Source: _docs/HIPAA_OPERATIONS_BLUEPRINT.md → Gate 3

What happens next?

Compliance reviews every request within five business days.

We contact you to verify your identity through the channel you provided. Records are not released until identity is confirmed.

Records are delivered within 30 calendar days per HIPAA Section 164.524. One 30-day extension is allowed if you are notified before the original deadline.

Requesting on behalf of someone else?