The American Health Information Management Association (AHIMA) is pleased to provide a model Patient Request for Health Information form to assist patients and providers in understanding and complying with patients “individual right of access” to their information as required by the Health Insurance Portability and Accountability Act (HIPAA). This model form is written at an 8th grade reading level to assist patients and can be used and customized by providers and organizations to capture patient request information.

The “Explanation for Use of AHIMA Patient Request for Health Information Model Form” – the reverse side of the model form – contains additional information, including links to related HIPAA specific requirements and resources to assist in a better understanding by patients and providers.

AHIMA hopes you find this model form to be helpful in connecting patients with their health information.
For more information regarding AHIMA, its mission, vision and work, or to become a member of AHIMA, please visit,

Click here to view the form