Julie D. Wood, MA, LMHC

Bellefield Office Park

1715 114th Avenue SE

Bellevue, WA 98004

425-868-4188

Request to Access to Review or Copy Record

Date ____________________

Client Name ____________________________________Birthdate_________________

Address to send copy______________________________________________________

I am requesting access to my record for the following purpose:

[    ] I wish to review my record on site at the following date and time:___________________

[    ] I am requesting a copy of a portion of my record: (indicate which portion)

________ __________________________________________________________________

[    ] I would like to have a written summary of my record, subject to agreement by therapist.

I understand that I will be charged a reasonable fee for a copy of the record, portion of the record, or a summary of the record and that the therapist may withhold the copy until the fee is paid. The fee is $20 plus .80 per page for the first 30 and .30 per page thereafter.

I understand the record or summary will be provided in paper format; that I will be informed if the record or part of the record does not exist or cannot be found; or if the therapist does not maintain the requested record, she will inform me (if known) who (health care provider) does maintain the record. I understand that any information not generated by this office or referencing another party and subject to confidentiality may be redacted.

I understand my request may be granted or denied. In either event, the request will be responded to as promptly as possible, but no later than 15 working days after receiving the request. In the event that unusual circumstances delay a response and the request has been granted, I will be informed in writing for the reasons for the delay and the earliest date (not more than 21 working days after the request is received) that the record will be available for examination or copying.

Client Signature_______________________________________________Date______________

(Or Personal Representative/parent)

Julie Wood, MA, LMHC____________________________________Date recieved___________