Request for Access to PHI

Caring Partners of Morris/Sussex, Inc.
200 Valley Road Suite 406, Mount Arlington, NJ 07856
Phone: 973-770-5505 Fax: 973-770-5557

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Request for Access to Protected Health Information

This form is used for a family to request copies of the youth's protected health information (PHI). This form gets sent to the Caring Partners Quality Department who processes all requests for PHI. You will be contacted within a few days of receipt of this request to confirm that we have received it and to verify the method of sending you the records.
Youth Name *

First Name Last Name
CYBER ID# *
If you know the CYBER ID, please provide, otherwise type in 99.
Youth Date of Birth *

Month Day Year
Care Manager
If the youth is transitioned, please give the name of the last Care Manager you worked with.
Name of person completing request *

First Name Last Name
Relationship to Youth *
Mother, Father, Parent, Guardian, Aunt, Uncle, Self, etc.
Legal Authority to request records *
Phone Number *
Email (If provided, a copy of this request will be sent to you by email. Email will be used only for purposes authorized or requested by you.
example@example.com
Date of request *

Month Day Year Hour Minutes AM/PM Option
Reason for request
Type of records requested (check all that apply): *

Individual Service Plan(s)* Strengths and Needs/CANS Assessment(s)*
Timeframe of records requested:
Note: By default, we will send you the first two plans and assessments and the last two plans and assessments from the current or most recent enrollment. Please indicate if you are interested in a different timeframe, for example: 'Records between X and Y dates' or 'All plans and assessments from the current (or last) enrollment'
Send: *

Paper records to Requestor via mail. Email records securely to Requestor. Fax records to Requestor. I will pick up paper records at Caring Partners office. Please call me when records are ready.
Send paper records to Requestor Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email Information: You have requested the records be emailed to you.

Please note that we will verify your email address first and then a secure email will be sent with the records and you will have to click to get a one-time passcode to open email.
Send electronic records to Requestor Email Address *
example@example.com
Private Fax Number *
Date needed by: (Please note we have up to 30 days to respond to record requests but try to complete all requests within 2 weeks. If you need the records sooner for follow up care or other urgent need, please indicate below.)

Month Day Year
Reason for urgent request or any other comments or special instructions:
Signature of Parent/Legal Guardian *

Clear
Name of person signing form *

First Name Last Name
Please read attestation and click box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
You will be contacted within a few days of receipt of this request to confirm that we have received it and to verify the method of sending you the records.

Note that there may be a charge for copies per the organization's policies. If so, a staff member will contact you to discuss the charges.
DocDate *

Month Day Year Hour Minutes AM/PM Option
Geo Stamp
Should be Empty:

Request for Access to Protected Health Information