Request for Access to PHI

Patient Information

First Name

MI

Last Name

Date of Birth

Email

Phone

Your Information

First Name

MI

Last Name

Email

Phone

Mailing Address

Supporting Documentation

Your relationship to the Patient

Parent/Foster Parent

Guardian

Medical Power of Attorney

Executor of Estate

Document Upload

The facility has documented proof of my relationship to the patient on file i

I decline to upload supporting document(s) i

I will upload supporting documents(s) i

I have documentation to support my relationship to the patient and will provide it to theBothwell Regional Health Center representative today i

Upload supporting document(s) (Court Order or Medical Power of Attorney):

Authorization to release my medical records

I authorize

Bothwell Regional Health Center

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

Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information

Your Information

Supporting Documentation

Authorization to release my medical records

Information to Release

Disclosure of sensitive information

Delivery Method

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

For use by a parent, or legal guardian, requesting medical records of a patient For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information Patient Information

Your Information Your Information

Supporting Documentation Supporting Documentation

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

Information to Release Information to Release

Disclosure of sensitive information

Delivery Method Delivery Method

Authorization for Release of Medical Information

For use by a parent, or legal guardian, requesting medical records of a patient

Patient Information

Your Information

Supporting Documentation

Authorization to release my medical records

Information to Release

Delivery Method