PRESTON MEMORIAL HOSPITAL - Welcome to Mon Health
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INSTRUCTIONS: Authorization to Use or Disclose Health Information
Dear Patient/Requestor,
In order to release health care records, please complete the enclosed Authorization to Use or Disclose Health Information
All areas must be completed, or the release will be unable to be processed.
In order to process your request as quickly as possibly we ask that you follow these instructions carefully.
Section I: Patient Information Section:
Please insert/write in:
Patient full name (last name, first name, middle initial)
Patient date of birth
Patient Account Number – if known
Patient Telephone Number
Patient last 4 SSN
Section II: Purpose of Disclosure:
Check one box to indicate why the health information records are being requested.
If checking “other” please insert/write in the reason
Section III: Method of Delivery:
Check one box to indicate the delivery choice
If requesting facility other than PMH (i.e. Ruby, UPMC) please insert/write in the name of the facility, phone, fax, address)
Section IV: Covering the period(s) of healthcare:
Insert/write in the date(s) of service you are authorizing to be copied/disclosed
Section V: Specific Information to be disclosed:
Check the boxes of items you need copied. Note: if you check pertinent Health record all dictated reports and testing results will be included)
Section VI: Sensitive Information to be Disclosed:
Must be completed
VII. Signatures:
All patients 18 years and older must sign authorizing disclosure of their Health Care Record with the exception of behavioral health records where the age of consent is 14.
If you are Medical POA or Executor of Estate, you must include those documents with this authorization.
2/22/2018
Authorization to Use or Disclose Health Information
Note: this is a two-sided form
I. Patient Information:
Patient Name: _________________________________ Date of Birth: ______________/_______/_____________
(Last) First) (M)
Account Number: __________________________ Telephone Number: _________________ Last 4 of SSN: ____________
II. Purpose of Disclosure:
□Self □ Insurance □ Attorney □ Disability □Physician □Other: ________________________
III. Method of Delivery :
□ Mailed □Electronic Media / CD □Pick up (Date: ________ Time: ___________ AM/PM)
I hereby authorize Preston Memorial Hospital or ___________________________________________________________
To release the following information to: (Facility Name)
____________________________________________________________________________________________________
(Name/Provider/Facility) (Phone) (Fax)
____________________________________________________________________________________________________
(Address) (City) (State) (ZIP)
IV. Covering the Period(s) of Healthcare: (You are only permitted to view information dated on or prior to date of this authorization)
From (date): _____/_____/__________ To (date): _____/_____/__________
V. Specific Information to be Disclosed:
□ Pertinent Health Record (dictated reports, test
results)
□ Discharge Summary
□ ER Record
□ Radiology CD/Films
□ Outpatient Rehabilitation (PT-OT-ST)
□ Operative Report
□ Lab Results
□ Radiology Reports
□ History & Physical
□ Pathology Report
□ Consultation Report
□ Physician Center Chart Notes
□ Urgent Care Chart Notes
□ Billing Statements
□ Complete Health Care Record
□ Clinic Visit: _______________
□ Other: __________________
Rev: 2/22//2018 Auth: HIM Manager
Scan: Authorizations
Pt. Name: ________________________
VI. Sensitive Information to be Disclosed: (Patients 14 years or older, MUST sign authorization form for sensitive information)
Required – Please complete the check boxes below indicating how protected information should be handled even if the categories do not apply to the patient’s health care record:
Initial each line below
□ I DO □ DO NOT want information about Mental Health released ___________________
□ I DO □ DO NOT want information about AIDS/HIV, Related Information released ___________________
□ I DO □ DO NOT want information about Alcohol and/or Substance Abuse released __________________
□ I DO □ DO NOT want information about ___________________________ released ___________________
VII. Signatures
• I understand that I may revoke this authorization in writing at any time, provided that I do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy
• Unless revoked earlier, this authorization will expire six months from the date of signing or until ________________.
• I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by federal privacy regulations. However, the recipient may be prohibited from disclosing substance abuse information under federal substance abuse confidentiality requirements.
• I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits.
• I understand I may be given a copy of this authorization form after signing.
|I certify and acknowledge that I have read this form and any related materials, or had it read to me. All my questions have been answered and I request that the |
|records be released as described above. |
| |
|Patient / Legal Representative: __________________________________ Date: _____________________Time: _________ |
| |
|If signed by legal representative, relationship to patient: ______________________________________________________ |
|(Copy of Power of Attorney or Executor Papers are Required) |
|Consent by responsible person because: ☐Minor ☐Unconscious ☐Other Explain: ________________________________ |
|Relationship of signer to patient: __________________________________________________________________________ |
| |
|Witnessed by: ___________________________________________Date: __________________________Time: __________ |
Please Mail or Fax completed authorization to:
Preston Memorial Hospital
Health Information Management Department – Release of Information
150 Memorial Drive
Kingwood, WV 26357
FAX: 304-329-2822
Your request for copies of Health Care Records will be processed as soon as possible; note the federal regulations time frame is 30 days.
Office Use:
Verify the following: □ Photo ID (walk in patient) □ Signature Comparison (mailed, faxed, emailed ROI)
Person Completing request: ____________________________ Date: _________________ Scanned: ___________
-----------------------
150 Memorial Drive
Kingwood, WV 26537
(304) 329-1400
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