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

Stony Brook Southampton 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)

* No Charge

Abstract (Subset of records) i

Autopsy Report i

Cardiac Testing * i

Cardiac CD * i

Consults i

Discharge Summary i

Emergency Record i

Endoscopy/Colonoscopy i

Laboratory Testing* i

Operative Report(s) i

Pathology Report(s) i

Radiology (X-Ray, MRI,etc.) (written report only)* i

Radiology Image CD* i

Complete Record i

From Date i

To Date i

Disclosure of sensitive information

I understand that this may include sensitive information relating to:

Psychological/Psychiatric conditions i

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

HIV AIDS diagnosis and/or treatment i

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

Genetic Testing i

Delivery Method

Released By

Only you may receive your records for a flat rate of $6.50 by choosing one of the following options:

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

Mail Paper Records i

Mail CD/DVD 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