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Request for Access and Authorization for Use and/or Disclosure of Protected Health Information

Please allow a minimum of three business days to process your request.

I understand that the protected health information specified below may include mental health, substance abuse (e.g., drugs, alcohol) HIV/AIDS status

information, diagnostic and treatment records.

I have read and understand the following statements:

I may revoke this authorization at any time by notifying the Health Information Management department in writing.

I understand that my revocation does not affect any disclosure made prior to the revocation being received and processed.

I understand the information disclosed may be subject to redisclosure and no longer be protected by federal or state privacy laws.

I understand that I am signing this form voluntarily and I am signing this under my own free will. Florida Hospital will not condition my

treatment, payment enrollment in health plans or my eligibility for benefits by signing this form.

I understand that I will receive a signed copy of this form.

I further agree to pay charges to provide the information request per Florida Statute 395.3025.

I understand that unless otherwise revoked, this authorization will expire upon the following date, event or condition: ________________.

If no expiration date, event or condition is noted this authorization will expire 1 year from the date signed.

I am the patient and I understand and agree to the provisions of this form/authorization

I understand and agree to the provisions of this form on behalf of the individual indicated below to be the patient. I have signed my name

individually as the representative of the patient and have attached a copy of the court order designating me as the guardian of the patient, or

documentation designating me as the Legally Authorized Person (LAP) of the

patient.

Patient’s Legal Name:

________________________________________________

MRN: _____________________________

Address:

__________________________________________________________

Date of Birth:

_______________________

__________________________________________________________________

Last 4 of SSN:

_______________________

Patient Phone Number:

______________________________________________

I authorize Florida Hospital to:

Disclose to

Obtain from ______________________________________ and send to below requestor.

Name:

_______________________________________________

Address:

______________________________________________________

City:

__________________________________

State:

_________

Zip:

_____________

Phone:

_______________________________ Fax: _______________________

Paper

Electronic (please contact Health Information Management for details)

I understand that all records will be mailed unless specified.

Pick Up at ____________________ Hospital

The purpose of this request:

Personal Request

Treatment (Continued Care)

Other: ___________________________________________

Please furnish the following information specified below for the following Visit Dates: _________________________Check appropriate boxes below

Abstract of Record (Dictated Reports, laboratory, cardiology, radiology)

Emergency Department Records

Discharge Summary

Operative Report(s)

History & Physical

Laboratory Reports

Billing Records

Pathology Reports

Radiology Report(s)

Complete chart

Other: ______________________________

Patient Signature:

_____________________________________________

Printed Patient

Name:_____________________________________

Legally Authorized Person Signature:

_____________________________

Name:_____________________________________________

Witness Signature:

____________________________________________

Name:_____________________________________________

Date

:______________________________

Request for Access has been:

Granted

Partially Denied

Denied

If access is denied and patient requests review of denial, contact the Release of Information office below.

Medical Records released/accessed: Date of release/Access______________________

By:______________________________________

Release of Information Contact Information Mailing Address only:

Florida Hospital Health Information Management

Release of Information

701 E. Altamonte Dr, Suite 2000

Altamonte Springs, FL 32701

Phone: 407-303-9175 Fax: 407-303-0633

You have the right to complain to the Office of Civil Rights. The following is the contact information:

Office of Civil Rights ~ U S Department of Health & Human Services 61 Forsyth Street, SW. Suite 3B70 Atlanta, GA 30323 ~ Phone# 404-562-7886; 404-331-2867 ~ Fax# 404-562-7881

Patient Name__________________________

Request for Access and Authorization for Use and/or Disclosure of Protected Health Information

FIN_____________ MRN_______________

Tab: Legal Forms & Consents

DH: Release of Information

768-0600 (1/12) MPC 765

or Patient Label

Request For Access And Authorization For Use And/or Disclosure Of Protected Health Information Form - Florida Hospital Health Information Management

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