privacy (hipaa) information

The following forms are to be used in connection with patient’s guaranteed rights under HIPAA:
Please note: Please use our Location Finder tool on this site for center contact information (i.e. phone, mailing, address, fax). For closed sites, please submit relevant form to the Privacy Office (email:[email protected]); fax:214-775-4408; mail: 4714 Gettysburg Rd, Mechanicsburg PA 17055).

• Access Records Request— This form is used for the patient to request access to the patient’s own protected health information (PHI). Submit to the Medical Records Custodian for the center where the patient was seen.
  • English Access Records Request Form (PDF,207 KB) — Spanish Access Records Request Form (PDF,201 KB)
• Consumer Authorization Request:— This form is used for a patient to authorize/direct PHI to a designated individual/entity. Submit to the Medical Records Custodian for the center where the patient was seen.
  • English Consumer Authorization Request Form (PDF,213 KB) — Spanish Consumer Authorization Request Form (PDF,210 KB)
• Amend Records Request — This form is used to request an amendment to clinical information in a patient’s medical record. Submit to the Medical Records Custodian for the center where the patient was seen. NOTE: Clerical errors are not requests for amendment and should be addressed to the treating location staff.
  • English Amend Records Request Form (PDF,205 KB) — Spanish Amend Records Request Form (PDF,188 KB)
• *Confidential Handling Request — This form is used to request an alternate method of communication other than what is on the file for confidentiality reasons. It should NOT be used for Access or Authorization requests.
  • English Confidential Handling Request Form (PDF,159 KB) — Spanish Confidential Handling Request Form (PDF,180 KB)
• *Restriction Request — This form is used to limit or restrict PHI from being disclosed to specified individuals (not applicable to workers’ compensation).
  • English Restriction Request Form (PDF,183 KB) — Spanish Restriction Request Form (PDF,181 KB)
• Complaint Form — Please contact center leadership where you received services to submit a privacy related complaint/concern. You can also contact the HIPAA Hotline at 800-819-5571. For non-privacy related customer service matters, please contact the Concentra Customer Care line at 1-866-944-6046.
  • English Complaint Form (PDF,178 KB) — Spanish Complaint Form (PDF,177 KB)
• Disclosure Accounting  Request — This form is used for a patient to request a list of disclosures of his/her PHI other than the type of disclosures bulleted within the form.
  • English Disclosure Accounting Request Form (PDF,202 KB) — Spanish Disclosure Accounting Request Form (PDF,199 KB)

*These rights may be limited for certain services, such as workers compensation.