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It records whether the client will view or copy records, explains access rights and required authorization or proof of guardianship, and outlines processing timelines, denial notice requirements, and denial/redaction rules. The fee section specifies flat charges plus tax, exemptions for certain summaries and short requests, payment handling, delivery methods, and office-use steps for approvals, invoices, record release, and appeals.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/request-to-access-a-record-and-copy-fee-agreement-template/283022/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/request-to-access-a-record-and-copy-fee-agreement-template/283022.png","ImageObject",442,249,{"name":88,"@type":89},"Putri","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-05","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"Who can request access to the clinical record and what authorization is required?","Question",{"text":109,"@type":110},"The client, their legal guardian (with proof), or a representative with a current signed Authorization to Release Information can request access. The form also requires acknowledgement of copying fees.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What information and date range can be requested, and how do clients choose to receive records?",{"text":114,"@type":110},"Requests can specify categories such as discharge summary, assessment, lab results, medications, after visit summary, and other items, along with a from-to date range. The client selects whether to view or copy and chooses delivery by encrypted USB, encrypted email, or paper copies.",{"name":116,"@type":107,"acceptedAnswer":117},"How are copying fees calculated, and when are there exemptions or no-fee cases?",{"text":118,"@type":110},"A flat $6.50 fee plus tax applies to requests to access records from the client or client representative. No fee is charged for basic information to another healthcare provider, and no fee applies for certain summaries or requests of 10 pages or less, as well as listed special circumstances.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283022,1790120204,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},962085571259,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","REQUEST TO ACCESS A RECORD  \nFor use when a client or their representative makes a request to view or copy the clinical record.  \n\n| Date of Request: |  |  | DOB: |  |\n| --- | --- | --- | --- | --- |\n| Client Name: (last, first, middle) |  |  |  |  |\n| Previous / Maiden Name or Alias: |  |  | Phone Number\u003Cbr>to Reach You: |  |\n| Name of requestor (if different): |  |  | Relationship: |  |\n| Current Address of requesting person: |  |  |  |  |\n\nInformation Requested:  \n\n| ☐ Discharge Summary (Free)☐ Assessment\u003Cbr>☐ In House Laboratory Results ☐ Medications\u003Cbr>☐ After Visit Summary (Free) | ☐ Letter to ( )☐ Treatment Summary (Free)☐ Progress Notes\u003Cbr>☐ Psychiatric Evaluations | ☐ Treatment Plan Reviews\u003Cbr>☐ Crisis Plan\u003Cbr>☐ Treatment Plan\u003Cbr>☐ History of Services (may include billing information)☐ Other: |\n| --- | --- | --- |\n\nDates Requested: from:   to:  . I wish to: ☐ View Record ☐ Copy Record  \nI have the right to access this information because:  \n☐ I am the client ☐ I am the legal guardian of the client (must provide proof of legal guardian/representative)  \n☐ I have provided a current Authorization to Release Information signed by the client/parent/legal guardian.  \nI have been given information about copying fees. I understand Compass Health may take up to 15 business days from receiving my request to make a determination regarding my request and arrange access to my records, or longer if an extension is needed. I will receive written notice if my request is denied, explaining the reasons for the denial.  \nSignature of Client / Guardian / Other  \n\n| FOR OFFICE USE ONLY: |  |  |\n| --- | --- | --- |\n|   Due date (15 business days from date received, please ensure received date is stamped on document) ☐ Extension requested Extension letter mailed on New due date (No more than 21 business days from date requested) |  |  |\n| ☐ Verified ROI on file, and the specific information requested is authorized by the ROI (if client/representative is not the requesting party.) |  |  |\n| ☐ Denied – ANY redaction constitutes a denial.☐ Information was not specified on ROI (if\u003Cbr>client/representative is not requesting party.)☐ Knowledge of the healthcare information could\u003Cbr>reasonably be expected to cause danger to someone’s life or safety or cause them substantial harm (requires explanation.)\u003Cbr>☐ Other (requires explanation.)\u003Cbr>*If denied letter must be sent to requestor. Sample available on SharePoint form 254a. Please document any details in the client HER warning if applicable. |  | Explanation of denial: |\n| Licensed Professional Reviewer Name (please print): |  |  |\n| Reviewer Signature: |  |  |\n\nCOPY FEE AGREEMENT  \n\n| Client Name/ID/DOB (or affix label): | This is not a release of information. A valid, signed release must be obtained prior to estimate being given, if requestor is someone other than client or legal guardian. |\n| --- | --- |\n\nCompass Health may charge a reasonable fee for providing health care information and is not required to permit examination or copying until the fee is paid (RCW 70 .02.080(2)) . All requests to access a record from a client or client representative will be a flat $6.50 fee plus tax* . *Applicable tax will be calculated and billed by the Medical Records Department when generating the final invoice.  \nNO FEE will be charged for providing basic information to another health care provider. This is a common courtesy provided for continuity of care. The provider must be listed on the release form to have the charge exempted.  \nNO FEE will be charged for client/guardian requests for the Transition Summary, a Treatment Summary, After Visit Summary, or any request 10 pages or less. If the information you request is over 10 pages, there will be charges as indicated above. Individuals appealing the denial of federal supplemental security income or social security disability benefits may receive one free copy of their health care information. Individuals that have been denied client portal access will re","cbCaie6nnC1JwNC2","https://ap.wps.com/l/cbCaie6nnC1JwNC2","pdf",278961,"English","# Request to Access a Record\n## Information Requested\n## Dates Requested and Access Choice\n## Authorization, Rights, and Processing Timeline\n## Denial and Office-Use Review\n# Copy Fee Agreement\n## Fees and Exemptions\n## Delivery Method and Contact Details\n## Office Use: Approval or Denial Workflow","[{\"question\":\"Who can request access to the clinical record and what authorization is required?\",\"answer\":\"The client, their legal guardian (with proof), or a representative with a current signed Authorization to Release Information can request access. The form also requires acknowledgement of copying fees.\"},{\"question\":\"What information and date range can be requested, and how do clients choose to receive records?\",\"answer\":\"Requests can specify categories such as discharge summary, assessment, lab results, medications, after visit summary, and other items, along with a from-to date range. The client selects whether to view or copy and chooses delivery by encrypted USB, encrypted email, or paper copies.\"},{\"question\":\"How are copying fees calculated, and when are there exemptions or no-fee cases?\",\"answer\":\"A flat $6.50 fee plus tax applies to requests to access records from the client or client representative. No fee is charged for basic information to another healthcare provider, and no fee applies for certain summaries or requests of 10 pages or less, as well as listed special circumstances.\"}]","Request to Access a Record and Copy Fee Agreement Template | PDF",1789587907]