I hereby request DCHC to provide me with access to my health information that DCHC holds about me in the DCHC designated record set in accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I understand that DCHC has 30 days to respond to this request and that DCHC may extend this 30-day response period for another 30 days if, within the initial 30-day period, DCHC provides me with a written statement of the reasons for the delay and the date by which it will respond. I understand that in certain circumstances DCHC may deny my request.
I also understand that DCHC may charge a reasonable fee associated with copying (including the cost of supplies and labor), postage (if you want the records mailed to you), and, if requested, for preparing a summary or explanation of any records. These fees are described in the Schedule of Charges attached to this form.