CareAllies Health Care Privacy Forms

To make a request, print and complete the appropriate form and mail it to the address indicated on the form.

If you want to obtain a copy of your health care information that Care Allies maintains, use this form:
Request for Access to Protected Health Information English | Español | Chinese 

If you want to identify someone else who will make health care decisions for you, use this form:
Request for Personal Representative English | Español | Chinese

If you want to allow someone else (such as a spouse, friend or attorney) to access your health care information, use this form:
Authorization for Disclosure of Protected Health Information English | Español | Chinese

To make a request, print and complete the appropriate form and mail it to the address indicated on the form

Written requests for an amendment to your PHI, an accounting of disclosures, statement of disagreement, or to change/revoke a prior request, may be mailed to:
CareAllies Privacy Office HIPAA UNIT,
PO Box 188014,
Chattanooga, TN 37422