You must also relate how long this release form is to be active, an expiration date if you will. If you have any medical history information that you do not want released, you must create a section on the document where you state this plainly. Be sure to go over the basic elements of composing a medical release form document we have listed above.įinally, remember to protect your privacy, and set the date. At this point you can be more specific, for example, include only a medical condition or your complete medical history, what medical information you wish to be shared, the purpose of the medical records release and recipients information. Next, state these words “I, authorize the release of my complete medical records and history to. For example, if you were not married at the time, you’d include your maiden name. The information you’ll need for this document is your birth date, social security number and include any name changes. This is necessary because it is illegal for any doctor to have access to your medical history without you allowing it. This is quite simple to do, as you are simply granting a medical professional or hospital the permission to look at your medical history that are from another doctor or clinic. The following section attempts to give you a bit of a background in the medical records release form, and helps explain the important parts of basic medical release forms. The second medical release form involves granting permission to administer medical care to a dependent if they are away from home. In this case, a form which lets a medical professional see your medical records. The first form is a medical history release form. There are two basic types of medical release forms. Important names, addresses, dates and signatures.What is the purpose or reason for the release of medical information.Who will receive the medical information.Who will disclose the medical information.What type of health information will be disclosed.An explicit opening statement which states the intent to release confidential health information, or PHI to an organization or medical professional.When you compose a medical records release form, or download one online, make sure it has the basic elements which include: Medical records release forms have certain elements which need to be included in order to meet the HIPAA medical privacy rules. If you have a form that needs to be completed by Central staff, please drop the form off at the front desk at the office location where you attend your appointments.Basic Elements of a Medical Records Release Form The completed forms may also be faxed to 26 or emailed to. Please return completed forms to our office at 1100 Powell Street, Norristown, PA 19401. If you have any questions regarding completing any of the forms or the status of your request, please contact the Medical Records Coordinator at 48, or email. We appreciate your patience! If your request is needed by a specific date, please indicate this on the form. Please note that we will attempt to complete your request as quickly as possible, but it may take up to 30 days to process your request. Please be sure to check all three boxes when completing the release if you would like copies of your clinical assessment, psychiatric evaluation, and/or progress notes to be released. Sample Completed Confidential ROI Please note that your records may contain information related to mental health, substance abuse, and HIV status. Confidential Release of Information Paper If you would like to view a sample of the completed form, please click the following link. If you would like Central staff to communicate with or send copies of your records to someone outside of the agency, (for example your family doctor, lawyer or probation officer), please complete a Confidential Release of Information form.Form # 343-Request to Access Protected Health Information Revised Draft If you would like to view a sample of the completed form, please click the following link. If you would like to request a letter regarding your treatment, please complete a Request to Access Protected Health Information form.Form # 343-Request to Access Protected Health Information Revised Draft If you would like to view a sample of the completed form, please click the following link. If you would like to receive a copy of your medical records, please complete a Request to Access Protected Health Information form.
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