Authorization For Release Of Health Information
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1
2JOHNS HOPKINS HOSPITALS
Johns Hopkins Hospital
Johns Hopkins Bayview Medical Center
Howard County General Hospital
Suburban Hospital
Sibley Memorial Hospital
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Complete all sections of this Authorization as appropriate to your request.
_____________________________________________
Patient Name:
Birth Date:
__________________
(first)
(m. initial)
(last)
____________________________________________
_______________
Address:
Phone #:
(street address)
_______
_
________________________________________
Medical Record #: __________________
(
(city)
(state)
(zip code)
if known)
WHO
I hereby authorize ______________________________________________________________________to take the following action.
(fill in above the name of the Johns Hopkins hospital where your medical information is held)
ACTION REQUESTED (check one)
Provide a copy of My Health Information to me
Let me look at My Health Information (I am not requesting a copy)
Release My Health Information to:
Discuss My Health Information with:
Obtain copies of My Health Information from:
________________________________________________________________________________________
(name of other person or entity)
_______________________________________________ ________________________________________
(street address)
(city)
___________________________ ________________________ ___________________________________
(state)
(zip code)
(fax number)
(We cannot call before faxing.)
WHAT
For this Authorization, “My Health Information” means (check one or more):
Abstract (discharge summary, operative notes,
Emergency Room Record
Outpatient Record
clinic notes, diagnostic testing)
History & Physical
Pathology Report
Billing Record
Immunization Record
Progress Note
Diagnostic Test/Results (lab, x-rays and
Mental Health Records
Other:________________________
other test results)
Operative Report
________________________________
Discharge Summary
If I have initialed here (________), “My Health Information” includes Substance Abuse Records/Information.
If I have initialed here (________), this Authorization does NOT include records from other healthcare providers that are a part of my
Johns Hopkins records included in this request. (If this blank is not initialed, those records will be included.)
For the date(s) of service from: _______________ to _______________
(records will be provided for all service dates if left blank)
(insert date(s) of service requested)
(Note: Information from recent visits may not yet appear in the record.)
WHY
□
□
□
□
At my request
For my healthcare / treatment
For legal purposes
For payment / insurance purposes
Other: _____________________________________________________________
A.2.1.c
Standard Register HIPAA-13N
Page 1 of 2
Copy – Medical Records
Copy – Patient / Representative
Effec. Date 9/20/13
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Parent category: Medical