Request for Access to PHI

Any disclosure of substance use disorder patient records is governed by Federal law (see 42 CFR part 2), and all disclosures of such records 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

Mailing Address

Authorization to release my medical records

I authorize

Eastern Long Island Hospital

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)

Medical Records Abstract i

Ambulatory Surgery i

Cardiology Report(s) i

Consultation Report(s) i

Discharge Summary i

ED Record i

Hospital Admission i

History and Physical i

Laboratory Results i

Operative Report(s) i

Outpatient/physician office record only i

Pathology Report(s) i

Physician Office Note(s) i

Radiology Report(s) 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 listed below. Please note only the items you check below will be released and no information will be released without your explicit consent. Include (indicate by checking below):

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

* If you select the option to not release any sensitive information, your records will have all sensitive information redacted. Please note that the information will not be released if you do not check at least one box.

Delivery Method

Released By

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

Mail CD/DVD i

Mail Paper Records i

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

Individual’s request

Medical Care

Insurance

Immunization

Legal

Today's Date

Consent Expiration Date i

Review & Submit for Signature

Cancel my request for records

Request for Access to Health Information by Patient

Patient Information

Authorization to release my medical records

Information to Release

Disclosure of sensitive information Revelación de información sensible

Delivery Method

Disclosure of sensitive information