Request Records

You have the right to inspect and copy the PHI contained in our Plan records. LIBERTY may charge you a fee for the costs of copying and mailing your records, as well as other costs associated with your request. LIBERTY will act on your request within 30 days. LIBERTY may deny a request for access to PHI under certain circumstances if there is a potential for harm to yourself or others. If we deny a request for access for this purpose, you have the right to have our denial reviewed in accordance with the requirements of applicable law.

To request a copy, complete the <Records Request> below:

First Name

Last Name

Address (line 1)

Address (line 2)

City

State

Zip Code

Phone

Email Address

Type of Records Requested

Dates of Service for Records Requested

Please only click Submit once

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Request Records