Please complete and return this form to your healthcare provider
who will return this form to Health Current.
Patients have the right to request a copy of their health information that is available through Health
Current, Arizona’s health information exchange (HIE). Patients also have a right to request a list of
the persons who have accessed their health information through the HIE in the last three years.
If you want to request any of this information, please complete and return this form to your
healthcare provider. You will receive a response to the request within 30 days. Please note, Health
Current may only send data to an address within the United States of America or its territories. If
you are filling out this form for another person, the references to “I” and “my” in this form refer to
that other person.