Request For Access To/authorization For Use And Disclosure Of Protected Health Information

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SSMHC “Request for Access to/Authorization for Use and Disclosure of Protected Health Information”
PATIENT NAME:_________________________________________________________________________________________________
LAST
FIRST
MI
Maiden or Other Name
DATE OF BIRTH:_____-_____-_____ FORMER NAME:____________________ MEDICAL RECORD #________________
MO
DAY
YR
ADDRESS:________________________________________________ CITY:______________________STATE:____ZIP:________________
DAY PHONE:________________________ EVENING PHONE:_____________________________
Type of access requested:
 Inspection
 Hard Copy
 Electronic Copy (this option is only available if SSM Health Care maintains the requested information
electronically)
I hereby authorize SSM Health Care to disclose my protected health information as indicated below to:
NAME: _______________________________________________________ RELATIONSHIP: ________________________
ADDRESS:_____________________________________________________________________
CITY:_____________________________ STATE:______ ZIP:_____________
PHONE:_______________________________________________
FAX:__________________________________________________
E-MAIL: ______________________________________________ (This option is only available if SSM Health Care maintains the requested
information electronically)
INFORMATION TO BE RELEASED:
DATES:
Discharge Summary
_________________
I specifically authorize the release of information relating to:
History & Physical Exam _________________
Substance abuse (including alcohol/drug abuse)
Progress Notes
_________________
Mental health or behavioral health
Lab Reports
_________________
HIV related information (AIDS related testing)
X-Ray Reports
_________________
X___________________________________________________
Medication Records
_________________
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE
Detailed Bill
_________________
Other (specify content and dates):____________________________________________________________________________________
PURPOSE OF DISCLOSURE:
Insurance/Workers’ Compensation
Changing physicians
Consultation
School
Research
At request of individual
Legal (specify): _________________________________________________________________________________________________
Other (specify): _________________________________________________________________________________________________
For personal access (specify):
Copy
Inspection
Summary
ACKNOWLEDGEMENT OF UNDERSTANDING:
I understand the expiration date of this authorization is
______________
at end of research study;
not applicable for ongoing
research.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the
date notified except to the extent action has already been taken in reliance upon it.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be
protected by Federal or State privacy regulations.
By authorizing this use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.
I understand that if I am being requested to authorize a use or disclosure that, upon request, I will get a copy of this form after I sign it.
I understand my request will be acted upon within 30 days. If I am not provided access or information cannot be supplied, I understand I will
be notified, and have the right to request review of any denial of access other than those made in accordance with applicable law.
I understand that I may be required to pay the cost of creating paper copies or electronic media, mailing copies, supervising my inspection, or
preparing a summary except for uses and disclosures for the purpose of treatment, payment, and operations.
SSM Health Care believes that the only way to avoid third party interception of information sent through e-mail is to send such information by
encrypted e-mail. Despite this warning about the risk that my protected health information could be read/intercepted by a third party if it is not
1406156v4 - P16 v1.3 Patient Access to Protected Health Information - Page 1 of 2

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