Request For Access Protected Health Information

This form allows an individual or their personal representative to request access to or obtain a copy of a record set maintained by Azova Inc. or the healthcare providers for which Azova Healthcare Inc. provides support services. If you are requesting records on behalf of the patient, please provide legal proof of your relationship, if you have not already. Azova will accept documentation such as an executed will, power of attorney, evidence of guardianship, etc., in addition to a valid government issued picture ID. The request may be denied by Azova under certain circumstances. Your request will be acted upon within 15 days unless Babylon provides written notification that an extension, of up to thirty (30) days, is needed.

To request access to your protected health information, submit a completed form to: privacy@azovahealth.com or mail to: Azova Inc, 144 S. Main St, Alpine, UT 84004, USA. Instructions on how to complete this form are provided below.

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.

NOTE: IF PATIENT IS UNDER 18 YEARS OF AGE AND IS NOT EMANCIPATED MINOR THE PARENT OR GUARDIAN MUST SIGN.

  1. Print legibly in all fields using dark permanent ink.
  2. Section I, complete all required sections notated by an asterisk (*).
  3. Section II, check the box of the records in which you would like to receive.
  4. Section III, initial next to any of the items that apply to this request.
  5. Section IV, provides the date range of records requested. Note: If you would like records to be presented up to present, present will be notated as the date in which the request form is signed and dated.
  6. Section V, check the format in which records are to be delivered in.
  7. Section, VI, check the box that best describes the recipient of the information and complete the contact information for the recipient.
  8. Section VII, please sign and date.

    I. Patient Information:










    II. What records do you want?

    (Check appropriate boxes) If all health information*, check only the first box.


    III. You must initial next to each to authorize for the requested items below:

    Mental health records (excluding psychotherapy notes)

    HIV/AIDS Test Results/Treatment

    Drug, Alcohol, or Substance Abuse Records

    Genetic Information (including Genetic Test Results)

    IV. Please produce records from the following dates:*

    (“present” equals date of signature)

    V. How would you like your records delivered?*



    * Azova will send the file via secure email unless another method is specified

    VI. Where do you want the information sent? (Fill in below)*










    VII. Acknowledgement

    NOTE: IF PATIENT IS UNDER 18 YEARS OF AGE AND IS NOT EMANCIPATED MINOR THE PARENT OR GUARDIAN MUST SIGN.

    By signing this form, I am acknowledging that I am requesting the records requested be sent to the address specified. I also acknowledge that if I have made more than one request for my records in the last calendar year, Babylon may charge me up to $6.40 for copying, postage, in connection with requests to mail these records. If I am denied access/inspection to the records requested, I understand that I may appeal the denial to the US Privacy Office at Babylon Health, located at, 2500 Bee Cave Rd, Bldg 1, Ste 400, Austin, TX 78746.



    If you have signed this form as a legally authorized representative of the Patient, please print your name and provide your relationship to the patient.



    Note: All sections with an asterisk (*) are required fields and this form will not be processed if all required fields are not complete.