Valdosta State University

Request to Inspect and Copy Protected Health Information

* Speech Clinic

* Student Health Services

* Athletic Department

* Human Resources

* Other. Please Specify ___________________________________________

Patient/Employee Name:________________________ Date of Birth:_________________________

Patient/Employee Address:

________________________________________

                           Street

________________________________________

                           Apartment #

________________________________________

                                    City, State Zip

I understand and agree that I am financially responsible for the following fees associated with my request: copying charges, including the cost of supplies and labor, and postage related to the production of my information. I understand that the charge for this service is $1.00 per page.

_________________________________________     _____________________________

Signature of Patient/Employee or Legal Guardian                                    Date

_________________________________________

Print Name of Patient/Employee or Legal Guardian

FOR INTERNAL PURPOSES ONLY:

Date Request Received:___________