Patient Health Information Authorization

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X1574-0414
PATIENT HEALTH INFORMATION AUTHORIZATION
I
NsTRucTIONs
  ❏ Mail records out to party I named in #3
  ❏ I will pick up records
  ❏ Patient given copy by Carle staff _______
-
❏ Farber
(initials)
ROI
       Mental Health requires Mental Health Authorization
❏ Hoopeston
1. PATIENT INFORMATION
Patient’s Name: __________________________________________
Birthdate: ____________________
Last 4 digits
Street Address: __________________________________________
of your SS#: __________________
City, State, Zip: _______________________________________
Clinic#: ________________________
Maiden/Other Names: ________________________
Phone#: (home)___________(work) ___________
I authorize the use/disclosure of my health information as follows:
2. P
h
(
)
ARTy whO hAs My
EAlTh INFORMATION
whO Is sENdINg yOuR INFORMATION
❏ Carle and any Carle entity
❏ Hoopeston and any Hoopeston entity
❏ Other Organization:
_______________________________________________________________
[N
]
[P
N
]
ame
hoNe
umber
_______________________________________________________________
[S
a
]
treet
ddreSS
_______________________________________________________________
[C
]
[S
]
[Z
]
ity
tate
iP
3. P
w
I
R
u
h
I
(
?)
ARTy
hO
wANT TO
EcEIvE OR
sE My
EAlTh
NFORMATION
whO wIll gET yOuR INFORMATION
❏ Carle and any Carle entity
❏ Hoopeston and any Hoopeston entity
❏ Other:
_______________________________________________________________
[N
]
[P
N
]
ame
hoNe
umber
_______________________________________________________________
[S
a
]
treet
ddreSS
_______________________________________________________________
[C
]
[S
]
[Z
]
ity
tate
iP
4. P
u
/d
M
h
I
uRPOsE OF
sE
IsclOsuRE OF
y
EAlTh
NFORMATION
❏ Medical follow-up
❏ Employment reasons
❏ Underwriting (insurance)
❏ Lawsuit
❏ Patient request
5. d
M
h
I
d
EscRIPTION OF
y
EAlTh
NFORMATION TO bE
IsclOsEd
chOOsE 1
A
(
Md)
bsTRAcT
FOR NEw
❏ Notes, X-Ray, Cardiac, for last two years, labs, last 6 months
s
I
/c
(
)____________________________________
PEcIFIc
NFORMATION
ONdITION
FOR MEdIcAl REcORds ONly
❏ All Dates
❏ Only Dates ____________________________________
c
c
OMPlETE
hART
❏ All Dates
❏ Only Dates____________________________________
b
R
IllINg
EcORds
❏ Dates____________________________________
O
I
ThER
NFORMATION
❏ Dates____________________________________
s
P
(
)
PEcIAlly
ROTEcTEd REcORds
chEck ANd INITIAl ThE FOllOwINg
_____ ❏
Alcohol/drug abuse treatment records
_____ ❏
Genetics
_____ ❏
HIV/AIDS/Sexually Transmitted Diseases
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