Authorization to Release information mRn - OhioHealth

[Pages:1]AUTHORIZATION TO RELEASE OF INFORMATION

1L.asPtANFTaoImEreNmTaIrNkFetOinRgMaAnTdIOCNommunications use onFliyr.st

MRN (OFFICE USE ONLY):

Middle

Maiden

6. media Public disclosure

Addreisas utHoRiZe tHe puBliC disClosuRe oF my peRsonal HealCtitHy inFoRmation as desCRiSBteatde BeloW:

Zip

DOB K name and age

SSN (LASKT 4cDiItGyIToS)f residence

Preferred Phone

K hospital admission, discharge or treated/releaLsEeAdVsEtaMtuEsSSAGE

K brief extent of injuries or illness

K diagnosis, treatment, prognosis

K photographs, videotape or audiota(CpHeECK TO LEAVE MESSAGE)

2. REASON FOR REQUEST

COKNoTtIhNeUr I(TdYesOcrFibCe)A_R_E__- _M_E_D__IC__A_L_T_R__E_A_T_M_E__N_T_________I_N_S_U__R_A_N_C__E__________L_E__G_A_L__R_E_A_S__O_N_S_______________D_I_S_A_B_I_L_IT_Y____________________

REFSoERAtRHCeH puRpose oF: K hospital produced publicatAioDnOs/PpTroIOmNotions/advertisiEngMPLOKYMhoEsNpTitaRl EevLeAnTtEs/Dpresentations/projects OtKhehro(Dspeistaclriwbeeb) - site K educational pu rposes/professional conference s K all news media 3. INFORMATION TO BE DISCLOSED BY: BEKRoGtEheRr HusOeS(PdIeTsAcLribe) _____________G_R__O_V_E__C_I_T_Y_M__E_T_H_O__D_I_S_T_H__O_S_P__IT_A_L________R_I_V_E_R__S_ID__E_M__E_T_H_O__D_I_S_T_H__O_S_P_I_T_A_L_________________________

DDOUaBCuLTthIONoRrMiSzEaHTtiOHoSOnPDaInITSdATLeHxOpSirPatIiToAnL:

HARDIN MEMORIAL MANSFIELD HOSPITAL

SHELBY HOSPITAL PHYSICIAN OFFICE (SPECIFY)

GRIADiYunMdEeMrsOtaRndIAtLhaHtOifSthPeITpAeLrson orenMtiAtyRtIhOaNt rGecEeNivEeRs AthLeHaObSovPeITiAnfLormation is not aOhTeHalEthRc:are provider or health plan covered by federal privacy GRANreTgMulEaDtioICnsA,LthCeEiNnfToErmRation describOed'BaLbEoNvEeSmSaHy ObeSPreITdAisLclosed by such person or entity and will likely no longer be protected by the federal privacy

4. DATErSegOuFlaStioEnRsV. ICE TO BE RELEASED:

DATEI/YEi AunRdOerFstSanEdRVthIaCtEtr(eSa):tmeFnRt OorMpayment of my claim will noTtObe impacted by not signing this form. research related treatment is strictly voluntary. 5. RECORDS TO BE RELEASED (CHECK ALL THAT APPLY):

AFITERi uVnIdSeIrTstSaUndMtMhaAtRbYy signing this auOthPoErizRaAtiToInVEit gRivEePsOthReT(rSes) earcher(s) the permPisLsEioAnStEo SusPeEoCrIFdYis:closure my personal health information for such

DISCHreAsReaGrEchS. UMMARY

EMERGENCY DEPT. REPORT(S)

RESULTS:

7. authoriZation

HCIOSINTSOiURuLnYTdASeNrsDtaPndHYthSaItCmAyL records/protecPCtAeOdTMHhPOeLaLElOthTGEinYRfoErmCaOtiRoDn

cannot

be

released

unlesOPsHTiHYsSEigIRnC:ItAhiNs

OfoFrmFI.CE

NOTES:

6. DEILIVaEsRdYesMcEriTbeHdOiDn:the notice of privacy practices of ohiohealth i understand that i may revoke this authorization in writing at any time, except to the extent

US MAthIaLt action has beenPItCakKe-nUPby ohiohealth in rCeDliance on this authorizationT,hbeyCsDe/nedminagilayowurihttaevnererevqouceastitoendtios: e(enncrtiytyp'tse)dm. Ief dyiocualargereceortdo dhaevpeartthmeent,

EMAIL(entity's address.) aMttnY:CinHfoArRmTation associateC. IOX E-PORTAL (limited per file size)

encryption removed by OhioHealth, please initial below. By removing the encryption, your personal health information will no longer be secured.

Emairl Aivderdsrideessh ealth center r iverside methodis t hospital grant medical center

INgIrTadIAy LmSe:morial hospital doctors hospital

doctors hospital nelsonville

7. RE(6L1E4A) 5S6E6-T50O0:0

(614) 566-5000

(614) 566-9000

(740) 615-1030

(614) 544-1000

(740) 753-1931

NAmMccEonOnFellPhEeRalSthOcNe/nOteRr GAdNubIZlinAmTIeOthNo/dCisLt IhNoIsCp:ital

ADDR(6E14S)S5:66-5356

(614) 544-8000

ohiohealth home care (614) 566-0888

marion general hospital C(7IT4Y0): 383-8400

hardin memorial hospital neighborhoodcaSrelf (419) 673-0761STATE: health ceZntIePr:

PHOmNaEr:ion area Physicians oPg oh Physicians group 8. PR(7O4H0)IB38IT3I-O80N10ON REDISC(6L1O4)S5U44R-8E3:76

o'bleness hospital (740) 592-9387

FmAeXd:central hospital (419) 526-8525

shelby hospital (419) 342-1715

IytphoureounvdrfieVbisreoliueeriomrsnanuitnasdsmoene)mf,adroatskhyftitihidnmasmigsnseleadaidn(dwnaiftcioyhccsaraahqflmutlaourartlrtilhehtroibeocietsednhor earsdihdmruuias.bitcnsmhjlefobooucserrntmuiezotronaaedttpdeiioooriffsoninccts,hliemioeifscsnhaueicenytdyilfodoifnnsrrbomcyuymlnanuadtddrinoreeeooncrtmiohFnereeexfdorcd)s,repemwpparasthratlwoyytli,tichoaooenttnfssRidcupieeCfefnriccntaiiifaieinnclndigtwty/oftroieirstrstdeptthnirRnoiscugteop,Gcnudt/seraipeadlongbCstnyeooo.fFsHFteihosededleoeprrtareatlRrrlsleaeRoawanet.tmgtFomueelwaendthtneioorotnamfslaHrinsetitdVgpa/ueto(elrHartattuahiionmasnstssa.anAa(n4uyig2melpCtnmeeFrRusrRaonelnopCadawourehttRhfo2iodc)vrisiemizonatalachtyityoaepntsrmofaohnariybyit

9. FEtEhSis: aPuetrhOorhizioatRioenvifsoerdreCleoadseesoafnpdroHteIPcAteAd, htheearlethminafyorbmeaatiocnhaforgrethfoerdcaotpeyoinf gsemrveidciecainl dreiccaotreddsis effective until ___________ or for a maximum of one year 10. AfUroTmHOthReIdZaAtTeIOsigNnAedNDbeEloXwP.IRATION:

8. eXPiration

+ Iintiuhfhoneerdmrreeearabstsyitoaonannuddstethahsonacrtdriziibfetietmh_dee_a_psb_epo_revs_eco_infm_ieo_adr_y.e_bn_et_itr_ye_dt_his_act(lornesacemedievbeyosfstehunecthiatypb)eortvoseodinnisfoocrrlomesnaettitiotyonatnihsdenwoptiallarltiykhee(playaltnhrtoicelasor)negnpearrmobveeidpeirnrootterhcihsteedadoltbhcyupmtlhaeennpct,roivivnaefcoreyrdmrebagytiuoflenadtifeorornamsl.pmrivyamcyedreicgaullaretiocnosrd, tfhoer + OhioHealth will not condition treatment, payment, enrollment or eligibility for benefits on whether you sign the authorization when the prohibition on condition

oXf austhigonraiztautrieonosf aPpaptileienst.______________________________________________________________________ date ___________ time ___________

+ I understand by signing this authorization it gives the researcher(s) the permission to use or disclose my personal health information for such research. + I undseigrsntatnudrethoaftimndyivriedcuoarldasu/pthrootreizceteddbhyePalathtieinnftor_m_a_t_io_n__c_a_n_n_o_t _b_e_r_e_le_a_s_e_d__u_n_le_s_s_I_s_i_g_n_t_h_is_f_o_r_m_.__________ date ___________ time ___________

+ I(AucnqdrueeirrsleatdatinoImdnsmthhuiapnt ottohdiesPfaaictuiieethnnotcr_yi_zSa_yt_ino_dn_r_mo_ma_ye_)_i,n_Pc_Slu_Yd_Ce_H_inI_Af_oT_rRm_I_Ca_tai_on_nd_/c_oo_rn_Dc_Re_rU_nG_in_/Ag_L_teC_s_Ot_iHn_gO_,_Ld_Tia_Rg_En_Ao_Ts_iM_s_Eo_Nr_Tt_re_aa_nt_dm_/oe_rn_At_oS_fS_H_A_IUV_L_(TH_uR_mECanOIRmDmSutnhoadt mefiacyiebneciynVmiryusm),eAdIiDcaSl record.

+ As described in the Notice of Privacy Practices of OhioHealth, I understand that I may revoke this authorization in writing at any time, except to the extent

thparot ahcibtiiotniohnaosnbeReendtiaskcelonsbuyreO:hiiouHndeearlsthtainndrethliaisnicnefoornmtahtiisonauhtahsorbizeaetniodni,sbcylosseenddfirnogmarwecriottredns rwehvoosceaticoonntfoidethnetiaelnittyityis'spHroetaelcthteIdnfboyrmFaetdioenraMl laanwa.geFmedeenrtal

MreedgiucalaltRioencso(r4d2s cDFerpaprtamrte2n)t.pIrfothhiibsitayuothuofrriozmatimonakhiansgnaontybfeuertnherervdoiksecldo,siut rweilol fexthpiisreinofonrmthaetidoanteexocreepvtewntithstathteedsbpeelcoifwic. wIfrinttoendactoenissesnpteocfiftiheed pbeerloswon, tthoe

aEwruxhetphogiormuarliatziittoaioptninoeDsnrtaaswtitenailsltoe.rreatmEhgavaeteinnnaentin:ryaelpfaefeurcsthtoofnorirwzaahtomiovanixofilomartuethmseaornfeyolenpaersoeyveiosaifor.mn eodfitchaisl olar wothshear lilnbfoermsuabtijoenc,t

if held by another party, is not sufficient to prosecution under Federal law.

for

this

purpose.

Federal

X Signature of Patient Date Time

Fees 9. redisclosure

SignaatcucreorodfiInngditvoidouahliAouRtheovriiszeedd bCyoPdaetsietnhte re is a per page fee for records . the fee will be dependDenatteupon the number ofTicmoepies requested and other reasons as specified in oRC 3701.741 at codes.oRC.

Relationship to Patient

PPaAtTiIeEnNtTiIdDeEnNtTiIFFiIcCaAtTioIOnNlLaAbBeElL

1011502105020(01(/10/1232/)20P1A5G) EPa1gOeF21of 2

auAtUHToHORRiIZZAaTItOiNoTnO to ReRlEeLEaAsSEeOiFnINFFoORRMmATaIOtNion

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download