Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Email

Phone

Mailing Address

Authorization to release my medical records

I authorize

Bothwell Regional Health Center

All Physicians

Name Physician(s)

Additional Locations

to disclose to

Me

or to

Named person or entity

A fee for medical record copies may apply. A patient whose records are copied and sent to another healthcare provider for the purpose of continuing to receive medical care does not pay a fee for medical record copies. Requests for medical record copies for any use other than medical care will be billed. The HIPAA Privacy Rule permits healthcare providers to impose a reasonable, cost-based fee to an individual requesting a copy of medical records. The fee may only include the cost of labor, supplies and postage

Name

Email

Phone

Fax

Mailing Address

Information to Release

What to Release (check all that apply)

Itemized billing i

Consultation by Dr. i

Discharge Summary i

ED Record i

EKG/EEG Reports i

Face Sheet i

Hospital Admission i

History and Physical i

Imaging films i

Immunization Records i

Interferon TB Test i

Laboratory Results i

Nursing Notes i

Operative Report i

Pathology Report(s) i

Physician Orders i

Physical Therapy i

Radiology Report(s) i

Titers i

From Date i

To Date i

Disclosure of sensitive information

You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions,treatments, or testing. Include (Indicate by checking below): Please note that the information will not be released if not checked.

Psychological/Psychiatric conditions i

Drug and/or alcohol abuse diagnosis and/or treatment i

HIV AIDS diagnosis and/or treatment i

Sexually transmitted disease(s) diagnosis and/or testing i

Genetic Testing i

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

Delivery Method

Released By

Receive electronic copy of records (this option is not available for radiology and cardiology images) i

Mail CD i

Print and Mail i

The purpose(s) for which disclosure is authorized (check where applicable):

Personal Reasons

Continuation of Care

Insurance Purposes

Immunization

Legal Purposes

Employer Requirement

Today's Date

Consent Expiration Date i

Review and Submit for Verification

Cancel my request for records

Authorization for Release of Medical Information Authorization for Release of Medical Information

Patient Information

Authorization to release my medical records Authorization to release my medical records

Information to Release Information to Release

Disclosure of sensitive information Disclosure of sensitive information

Delivery Method Delivery Method

Authorization for Release of Medical Information

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method