Medical And Bh Records Transfer To Jhc Form printable pdf download

Medical And Bh Records Transfer To Jhc Form

MEDICAL AND BEHAVIORAL HEALTH

RECORDS TRANSFER TO JHC FORM

I, ____________________________________________________________________________, hereby authorize the release of

Print Name

□

□ _____________________________________________________________________________

(OR)

’s

(must provide documentation of authorized relationship)

Medical Records to include (check all that apply):

□ Entire Medical Record

□ Mental Health Diagnoses

□ Criminal Justice Records

□ Social/Family History

□ Psychiatric Records

□ Financial Information

□ Medical Diagnoses

□ Psychological Records

□ HBV/HCV Information

□ Assessment Information

□ Educational Records

□ HIV/AIDS Information

Benefits/Services needed,

Substance use treatment

□

□ Other:_________________________________

planned, and/or received

/Drug Screens

*Note that JHC does not forward patient information from other medical offices to any other provider of care

To be sent to:

Medical Records Department

Johnson Health Center | Administrative Offices

134 Elon Rd

Madison Heights, VA 24572

Fax: 434-455-2487**

**Please mail if more than 15 pages

Items marked with an (*) asterisk are required for processing

Patient-specific Information

First name*:

Last name*:

DOB*:

Address:

(

)

Phone*:

Medical Office Information

Office/Practice name*:

Doctor(s) name(s):

Address:

City*:

State*:

Zip*:

Phone*:

Fax:

Signature:

Date:

I may revoke my consent at any time except to the extent that the Johnson Health Center has already

taken action on the original request for release of my medical information. This authorization will

automatically expire after 12 months (365 days) from the date on which it is signed. I understand that

refusal to sign this consent for release of information may result in the Johnson Health Center declining to

provide treatment to me in compliance with HIPAA/BPHC regulations pertaining to Federally Qualified

Health Centers.

JHC Policies and Procedures/Forms/Medical and Behavioral Health Records to JHC Form

10/15/14

Medical And Bh Records Transfer To Jhc Form

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