Request for Access to Health Information by Personal Representative.

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.

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

Patient Information

First Name

Last Name

Date of Birth

Phone

Your Information

First Name

Last Name

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 theEastern Long Island Hospital representative today i

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

Authorization to release my medical records

I authorize

Eastern Long Island Hospital

to disclose to

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

Phone

Fax

Mailing Address

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 Form Expiration Date i

Review & Submit for Signature

Cancel my request for records

Request for Access to Health Information by Personal Representative.

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 Revelación de información sensible

Delivery Method

Disclosure of sensitive information