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

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:

1.

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

2.

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

3.

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

4.

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.

5.

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

6.

I further agree to pay charges to provide the information request per Florida Statute 395.3025, to Healthport, ROI contractor for Florida

Hospital Tampa.

7.

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: _____________________________

Print Name:_____________________________________________

Witness Signature: ____________________________________________

Print 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

3100 E. Fletcher Ave.

Tampa, Fl. 33613

(Phone) 813-615-7200 (Fax) 813-615-7861

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__________________________

FIN_____________ MRN_______________

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

Tab: Authorization for release of information

DH: Release of Information

or Patient Label