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 amend or correct health care information that Care Allies created, use this form:
Request to Amend Protected Health Information English | Español | Chinese 

If you want to learn whether Care Allies has released any of your health care information to a third party, use this form:
Request for Accounting 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 either request a change to or cancel any of the above requests, use this form:
Change/Revoke Request 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