Form 101 - Authorization For The Release Of Protected Health Information

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Form No. 101 6/2015
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH
INFORMATION
Fax:
402-498-6712
Email:
Patient Name: _____________________________________________________Date of Birth: ____________________
Address (including City/State/Zip)_____________________________________________________________________
________________________________________________________________________________________________
Phone Number: ___________________________________________________________________________________
I request that my protected health information (PHI) from Boys Town National Research Hospital be disclosed to:
Release Information From:
Release Information To:
Provider/Facility Name: ____________________________
_______________________________________________
_______________________________________________
_______________________________________________
Address: _______________________________________
Address: _______________________________________
City/State/Zip: ___________________________________
City/State/Zip: ___________________________________
Phone: ___________________ Fax _________________
Phone: ___________________ Fax _________________
Information to be Released:
Service Dates: From: ________________ To: ________________
Clinic
Hospital
Ancillary
Other
Allergy
GI
History & Physical
Lab
Immunization Record
Neurology
Ophthalmology
Consultation Reports
EEG
Itemized Billing Records
Craniofacial
Orthopedic
Operative Report
EKG
Nutrition
Internal Medicine
Pediatric
Discharge Summary
Sleep Study
School/Work Release
Audiology/Cochlear
Psychiatry
Anesthesia Records
X-ray
Verbal Communication
Ear, Nose, Throat
Speech & Language
CT/MRI
Other:
Behavioral Health
Purpose for which information is to be used:
Treatment/Referral
Insurance
Evaluation
Changing Doctors
Personal/At Request of Patient
Other (Please specify)
Please check any of the following condition(s) that this authorization applies to:
Chemical Dependency/Alcoholism or Abuse
HIV Information
Mental Health Information
Release Format:
Release Method:
Paper
CD/DVD
Mail
Pick up
Fax
Email
Portal
By signing this authorization form, I understand that:
I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the Medical Records
•
th
Department at Boys Town National Research Hospital at 555 North 30
St. Omaha, NE 68131. Revocation will not apply to information that
has already been disclosed in response to this authorization.
Unless otherwise revoked, this authorization will expire in one year from the date signed or on the following date/event/condition
•
______________________________________, whichever occurs sooner.
Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this authorization.
•
Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal
•
confidentiality rules.
Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.
•
Patient or person authorized to sign for patient
Relationship to Patient
Witness
Date

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