AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT ... - IU Health
Date of Birth ______ ... clinic.) Receiving Party: (Where do you want the information sent? Who may ... State and federal law protect the following information.
AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION PATIENT INFORMATION
Name _____________________________________________________________ City __________________________________ State __________ Zip _________
Clinic/Hospital/Health Care Provider: (Who has the information you want released? Please list the specific Hospital and/or clinic.) Receiving Party: (Where do you want the information sent? Who may have the information?) Information to be Released: (What do you want sent or released? Check the appropriate box.)
Special Authorization Section (Per IC-16-39-2 this special authorization is valid for 180 days.)
Release Instructions: (How and When do you want the information?) Purpose of Release: (Why is it needed?)
Date of Birth __________
Address ___________________________________________________________ Day Phone ___________
Name ______________________________________________________________________________________ Address ____________________________________________________________________________________ City ___________________________________________________________ State __________ Zip___________ Phone Number _______________ Fax Number _______________ Name ______________________________________________________________________________________ Address ____________________________________________________________________________________ City ___________________________________________________________ State __________ Zip___________ Phone Number _______________ Fax Number _______________ Attention to ____________________________ Physician Office Medical Records Hospital Medical Records Date(s) of Service: From _____/_____/_____ To _____/_____/_____ Billing Records Copies of Films/Images Any and all records (includes ALL types of records listed below. If you want to include images and billing records, check those boxes.) Only record types checked below: Discharge summary/note Radiology reports Emergency record(s) History & Physical Exam Rehab records (PT/OT/ST) Immunization/allergy record Operative report Laboratory reports Pathology reports Consultations Progress Notes Other records (Specify record types(s) ______________________________________________________ State and federal law protect the following information. If this information applies to you, please indicate if you would like this information released/obtained (include dates where appropriate): Alcohol, Drug, or Substance Abuse Records HIV Testing and Results Mental Health Records Psychotherapy Records Genetic Records
Release Method/Format requested: (check one) Paper Email ____________________________________ E-mail address for link
Date information is needed _______________________ NOTE: Please allow 5-10 business days for processing Continuing care Transfer of care Social Security appeal Insurance application* Personal use or review* Social Security Disability Determination* Insurance payment/claim Litigation/legal* Other* _______________________________ *Fees may be charged in accordance with IN Statute 760 IAC 1-71-3 and Federal Rule 45 C.F.R. §164.524
• This authorization will expire in 60 days from the date signed unless otherwise specified ________________________________ • I understand that I have the right to revoke this authorization at any time. In order to revoke this authorization, I must do so in writing and present my written revocation to the above named authorized entity. The revocation will not apply to information that has already been released in response to this authorization. • I understand that I am not required to sign this Authorization in order to receive health care treatment. • IU Health Physicians’ records may include records that it received from other organizations. If these records have been used by IU Health Physicians and filed in the record IU Health Physicians maintains about you, these records may be released with your IU Health Physicians records. • IU Health Physicians cannot prevent the disclosure of your information by the person ororganization who receives your records under this authorization, and that information may not be covered by state and federal privacy protections after it is released. By signing this authorization, you release IU Health Physicians from any and all liability resulting from a redisclosure by the recipient. Your signature indicates that you have read and understand this form, and you authorize release of your information as described above. _________________________________________________ __________ Patient/Legal Guardian Signature Date _________________________________________________ Authority to act on behalf of patient (Attach documentation) Corresp Non-Conf
*0019* 0019
To be completed by Staff: Initials of person releasing information _________ Date __________ Photo ID/Signature verified _________________________________ Medical Record Number _________________ Patient Encounter Number ____________________________________
AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION 56153 (0317) Page 1 of 2
Cost Patient personal and patient directive (request being sent to an attorney directed by patient) requests will follow the below pricing guidelines: Format of Original Patient Record
Electronic or Hybrid (part electronic part paper)
Paper
Cost for delivery in electronic format (CD, USB, Download, or Portal)
Cost for record delivered in paper
$6.50 flat fee for electronic portion
$0.12 per page for CIOX Health’s labor and supplies to deliver the portion of record maintained in paper. Plus, if applicable, sales tax and actual postage if mailed.
Plus, if applicable, $0.07 per page for CIOX Health’s labor cost to create and deliver the portion of record maintained in paper plus sales tax as applicable
$0.07 per page for CIOX Health’s labor cost to create and deliver the portion of record maintained in paper Plus actual postage if mailed plus sales tax as applicable
Plus, if applicable, the lower of cost under state regulated patient rates or $0.90 for CIOX Health’s average labor cost to create and deliver the portion of record maintained electronically.
$0.12 per page for CIOX Health’s labor and supplies to deliver the portion of record maintained in paper. Plus, if applicable, sales tax and actual postage if mailed.
**IUHP patient personal requests will be charged the above rates up to a cap of $25.00 plus tax and postage**
List any physical restriction or restriction for any activity on the basis of ... the Annual Diocesan Pilgrimage Steubenville Conference on: _July 13 – 15, ... defend the Roman Catholic Bishop of Las Cruces, and his successors, the Diocese of ... vol
Recommended Request for Records ... may disclose personally identifiable information from an education record of a student without the written consent of the.
DISCLOSURE and AUTHORIZATION TO OBTAIN INFORMATION. Divulgacion y Autorización para obtener información. In connection with my suitability for “volunteering* with OCSG (herein “Client') or if allowed to volunteer, I understand that prior to or at any
DISCLOSURE and AUTHORIZATION TO OBTAIN INFORMATION. Divulgacion y Autorización para obtener información. Con respecto a mi facuitad para "voluntario * con OCSG (aquí" cliente ") o si permite hacer un voluntario, entiendo que antes o en cualquier mome
Visitas Oncología/Quimioterapia. □ Informe(s) de laboratorio. □ Visitas quirúrgicas. □ Informes de pruebas genéticas. □ Informes de estudios diagnósticos por ...
incluyendo pero no limitada a proveer consentimiento o rechazar consentimiento para cuidado médico, cirugía, y/o ubicación en complejos de cuidado médico.
to be able to leave telephone messages when possible. There are also times where you may want us to communicate labs, ... patient, and to any public health agency to which IU Health Physicians is legally bound to report such information,.
Minor's Name (if applicable) / Nombre del Menor (si esto aplica):. Address / Domicilio: City, State ZIP / Ciudad, ... (a) registrar, usar, re-usar, publicar, y re-publicar y extender el derecho a registrar, usar, re-usar, publicar, y re-publicar, fot
to this release of information by giving notice to IU Health Physicians in writing. Health Insurance Portability and Accountability (HIPAA): I acknowledge that I ...
Tennessee Department of Health. Office of Quality and Patient Safety. Division of Health Care Facilities. The Joint Commission. Centralized Complaint Intake ...
11 ene. 2012 - Declaration made this day of. (month, year). I,. , being at least eighteen ... Ciudad, Condado y Estado de Residencia. El declarante me ha sido ...
Declaration made this day of. (month, year). I,. , being at least eighteen (18) ... Ciudad, Condado y Estado de Residencia. El declarante me ha sido presentado ...
1 oct. 2017 - Vision. EyeMed. Visit eyemedvisioncare.com/iuhealth or call ... civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad ...
... facilitate the education of the child named above. Thank you for your attention. □Diagnosis □Treatment/Medications □Recommendations □Limitations (PE) ...
In making a determination pursuant to section seven hundred fifty-two of this chapter, the ... request, a written statement setting forth the reasons for such denial.
National Pork Board • P.O. Box 9114 • Des Moines, Iowa 50306 USA • Phone: (515) ...... Administración Nacional de Bioseguridad de la Universidad de Purdue.
J.A. = Juan Andrés Herrera Ramos. Entrevistador: ¿Podrías contarnos tu motivación por jugar al fútbol? J.A.: De pequeño veía partidos por televisión y me ...
... CHILD TO TRAVEL TO CANADA. ** Complete this form in full, leaving no empty blanks. Failure to do so may result in processing delays**. Child's Information.
prescription asthma medicine while on school property if: 1. The prescription asthma ... I understand that by law the medicine must have a prescription label on it.
2 sept. 2005 - During the process of review and preparation, the papers have benefited from comments and ...... pharmaceuticals/inquiry/communication_en.pdf .... exercise personally or may assign or transfer by succession or licence.
Parents will not be asked to pay for any school health services. I consent for billing to Medi-Cal/Insurance carriers for school health services provided for my child ...
Procesamiento de Señales Biológicas). • Dra. Virginia Ballarin. Universidad Mar de Plata. Argentina. (Con doctorado en. Procesamiento de Imágenes médicas).
