Form Nonch35557 - Authorization For The Release Of Protected Health Information - Emory Healthcare
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1
2medical record number: ____________________________
(for internal purposes)
AuthorizAtion for the releAse of Protected heAlth informAtion
heAlth informAtion mAnAgement dePArtment
Patient name: _________________________________________ last 4 digits of ssn: ___________________________________
Previous name, if applicable: ______________________________________________________________________________________
Address: ____________________________ city: ______________________________ state: ________ zip code: ____________
date of Birth: _______________________ home Phone: _______________________ Work Phone: ________________________
email address _________________________________________________________________________________________________
1.
E
H
F
/F
:
mory
EaltHcarE
acility
acilitiEs
i authorize representatives from the following facility/facilities to disclose the health information as directed below:
(Check one or more):
❑
emory Johns creek hospital
❑
the emory clinic
❑
emory university hospital midtown
❑
emory university hospital
❑
emory university orthopaedics and spine hospital
❑
center for rehab. medicine
❑
Wesley Woods health center
❑
❑
emory children’s center
Wesley Woods geriatric hospital
❑
❑
emory specialty Associates
Wesley Woods outpatient clinic
❑
dialysis Access center of Atlanta
❑
Budd terrace
other: _______________________________________
❑
saint Joseph's hospital of Atlanta
❑
❑
the medical group of saint Joseph's, llc
2.
r
P
EcEiving
arty
Please send my health information to:
name: _____________________________________________________________________________________________
Address: ____________________________________________________________________________________________
city: __________________________________ state: ____________________ zip code: _________________________
telephone number: __________________________________________________________________________________
fax number (continuing patient care support only): ________________________________________________________
3.
D
H
i
t
B
D
:
EscriPtion oF
EaltH
nFormation
o
E
isclosED
complete medical record (Please specify dates of service) _________________________________________________
❑
OR
❑
Partial medical record (Please specify records below)
electronic continuity of care/electronic Abstract (please specify dates of service) _____________________________
❑
*not applicable to records maintained at the emory clinc and/or emory specialty Associates
❑
You must check this box if you are also requesting Billing Records
information
dates
information
dates
______
______
❑
history & physical
❑
office notes/Progress notes
______
______
❑
consultations
❑
operative reports
______
______
❑
discharge summary
❑
Pathology reports
______
______
❑
lab results
❑
Pathology slides
______
______
❑
X-rays
❑
eKg reports
______
______
❑
cd/films
❑
Photo/Videos
______
______
❑
cath record
❑
ed record
______
______
❑
itemized Bill
❑
rhythm strips
______
❑
❑
other (Please specify dates of service):
Pathology slides
4.
P
D
urPosE oF
isclosurE
❑
At my request
other: _______________________________________________________________________________________________
❑
Front
35557
nonch35557 07/12
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