Form V2-03-2015 - Right To Access And Consent For Release Of Protected Health Information (Phi) Form

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RIGHT TO ACCESS AND CONSENT FOR RELEASE OF
PROTECTED HEALTH INFORMATION (PHI)
POLICY: In the case of a verbal or written request for PHI (Protected Health Information) included in the Pharmacy’s Medical Expense
and Accounts Receivable Information, the Pharmacy will (at the discretion of the Pharmacist, Privacy officer, or person
receiving a written or verbal request) release patient specific information limited to and as included in it’s then current Medical
Expense and/or Accounts Receivable Information directly to the patient or authorized agent of the patient after having the release
herein previously completed.
PURPOSE: In any case where the requested information goes beyond the Pharmacy’s then current Medical Expense and/or Accounts
Receivable Information or a Pharmacy employee believes the patient’s PHI is best protected by having the release herein
completed prior to release of any PHI, this release serves as the documented request for the release of Protected Health
Information (PHI) to the patient or authorized agent of the patient as designated below.
I am requesting the following PHI (check only those that apply):
PRESCRIPTION MEDICATION ACTIVITY INFORMATION (detailed report including copay
information)
MEDICAL EXPENSE SUMMARY (total expenditures by patient)
PRESCRIPTION EQUIPMENT
or DEVICE
ACTIVITY INFORMATION (contact corporate)
PATIENT DEMOGRAPHIC INFORMATION (pharmacy or corporate)
BOOKKEEPING / ACCOUNT RECEIVABLE ACTIVITY INFORMATION (corporate)
CURRENT INSURANCE INFORMATION (FOR THE DATE OF REQUEST) (pharmacy or corporate)
OTHER (SPECIFIC DETAIL REQUIRED)______________________________________________________________
I, ___________________________________________ hereby authorize the release of my protected health information (PHI) to the
Print Name of Patient whose PHI is needed
following person or classes of persons:_______________________________________________________________________________
Name(s) Printed
This form is valid for only the dates requested. The specific time period for which records are being requested (no future dating
allowed) is ____________________to________________. I also certify that the records being requested are my own personal records.
DATE / MONTH / YEAR
Signature of Patient______________________________________Date___/____/___ Date of Birth ___/___/___
Please check the manner in which you prefer to receive this information:
Pick up at Pharmacy
Mail
Address:______________________________________________/_________________________/__________/________
Street
City
State
Zip code
This disclosure is being made for the purpose(s) of:____________________________________________________________
______________________________________________________________________________________________________
Routine requests processed at store level may typically be completed after 1 business day. (ask pharmacy staff) Depending on the type and
format, your request for information may take up to 30 business days. The information may be obtained here at the pharmacy or mailed (note
address above) to you at your request. This form must be completed in its entirety (no blank lines) and returned to begin processing
information. Failure to return this form will result in your request not being processed. Thank you for your patience.
Signature of Person Receiving PHI: _____________________________________________
Date: ____/____/_____
(must be authorized above)
Print Name of Person Receiving PHI: ____________________________________________
INTERNAL USE BY PHARMACY
Verify person receiving PHI (must be authorized) by inspecting a valid form of identification:
Driver’s License: Y / N
Or other form of identification: Y / N List type of ID:___________________________
Name of employee performing verification:_________________________ Signed:____________________________ Date______________
V2-032015

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