Request for Access to Health Information by Personal Representative.

Any disclosure of substance use disorder patient record governed by Federal law (see 42 CFR part 2) shall be accompanied by the following written statement

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any substance use disorder patient.

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 the Medical Practice Name representative today   i  

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

 

Authorization to release my medical records

I authorize

Medical Practice Name >Stony Brook CPMP-VRA

Medical Practice Name - Physician Offices

All Physicians

Name Physician(s)

Please enter a provider name below if applicable.

Please note, if you require records from multiple locations you will need to complete this form again for each additional location.

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)

Abstract (subset of records)   i  

Cardiac CD   i  

Complete Records   i  

Consults   i  

Discharge Summary   i  

Cardiac Testing   i  

Emergency Record   i  

Endoscopy/Colonoscopy   i  

Laboratory Testing   i  

Operative Report(s)   i  

Pathology Report   i  

Autopsy   i  

Radiology (X-Ray, MRI, etc.)   i  

From Date   i  

To Date   i  

Disclosure of sensitive information

I understand that this may include sensitive information relating to:

• Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection
• Behavioral health services/psychiatric care.
• Treatment for alcohol and/or substance use disorder.

Delivery Method

Released By

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

Encrypted Media (CD) via Mail   i  

Paper Records via Mail   i  

Today's Date

Consent Form Expiration Date   i  

Review & Submit for Signature

Cancel my request for records