Authorization For Disclosure Of Health Information printable pdf download

HEALTH INFORMATION DEPARTMENT

□ Buffalo Mercy Hospital

565 Abbott Rd. Buffalo NY 14220

716-828-2322

□ Sisters of Charity Hospital Main St. Campus

2157 Main St. Buffalo NY 14214

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION

716-862-1986

□ Sisters of Charity Hospital St. Joseph Campus

2605 Harlem Rd. Cheektowaga NY 14225

Please Note:

716-891-2157

There is no charge for records being released to a doctor or hospital.

□ Kenmore Mercy Hospital

2950 Elmwood Ave. Kenmore NY 14217

All other requests for records will be charged a fee of $.75 per page copied

716-447-6116

Patient Name:

_______________________________________________________________________________ DOB: ________________________________

Patient Address:

______________________________________________________________________________________________________________________

Telephone:

___________________________________

Cell Phone: ______________________________________

Date(s) of Treatment:

______________________

Type(s) of Treatment: ___________________________________________________________________________

This form authorizes the provider to disclose the following specific health information to the recipient named below. Portions of the medical record is available electronically and can be

provided to you on a CHS provided USB device for a nominal fee. Paper copies can be picked up in the Health Information Department 8am- 4 pm Monday – Friday or will be mailed to

you upon request.

□ Documents will be picked up

□ Please mail the information to me at the address below.

Name/Department: _____________________________________________________________________________________________________________

Email:______________________________

Address:

_____________________________________________________________________________________________

FAX: _______________________________

Information Requested:

□ Entire Record

□ Discharge Summary

□ Operative Report

□ Physician’s Notes □ X-Ray

□ Face Sheet □ History & Physical

□ Pathology Report

□ Laboratory

□ Clinical Letter

□ Discharge Instructions

□ Other: ___________________________________________________________________

This authorization is granted for the following purpose(s): ___________________________________________________________________________________________

This authorization is valid until ____/____/____ or until the occurrence of the following event: _______________________________________________________________

Or in any case not to exceed one year.

This authorization may be revoked by the undersigned individual at any time, by submitting a written notice of revocation to Provider. However, any revocation shall not apply to the

extent that Provider has taken action in reliance on this authorization.

The information disclosed pursuant to this authorization may be disclosed again by Recipient and if so, may no longer be protected by Provider’s privacy practices or

federal privacy regulations. However, in the event that these medical records include documentation of alcohol and/or drug abuse, the following statement

applies: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW.

FEDERAL REGULATIONS (42 CRF PART 2) PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF IT WITHOUT THE SPECIFIC WRITTEN

CONSENT OF THE PERSON TO WHOM IT PERTAINS, OR AS OTHERWISE PERMITTED BY SUCH REGULATIONS

By signing my name below, I hereby acknowledge that I have read and fully understand this form. I understand treatment, payment, enrollment in a health plan and

eligibility for benefits may not be conditioned on my signing this authorization. I acknowledge that I am signing this authorization voluntarily.

Only ONE of the following sections must be completed.

This section is to be completed if authorization is being given by the Individual:

Signature of Individual

Date Signed

This section is to be completed if authorization is given by a Personal Representative:

Name of Personal Representative:

Signature of Personal Representative

Date Signed

Description of Authority to act as personal Representative of the

Individual (e.g., Guardian, Attorney, Health Care Agent )

Form #PRIV-02-F01