SECTION A: Patient s name: Last: First: MI: Date of birth: Phone number: Medical Record Number:

Transcription

1 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 1 f 6 AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION When yu cmplete and sign this frm, health infrmatin abut yu will be released as yu describe in the frm. Please read each sectin carefully and cmplete the required sectins befre signing. We encurage yu t request a cpy f yur recrds and review them befre authrizing the release f the recrds t smene ther than yu. Please clearly and legibly print all infrmatin when cmpleting this frm and sign n the last page. SECTION A: Patient s name: Last: First: MI: Date f birth: Phne number: Medical Recrd Number: SECTION B: **Please check bx next t facility r ther prvider authrized t disclse the infrmatin: YOU AUTHORIZE: Stanfrd Health Care (SHC) Stanfrd, CA T: F: University HealthCare Alliance (UHA) 7999 Gateway Blvd #200 Newark, CA T: F: Stanfrd Health Care-ValleyCare (SHC-VC) 5555 W. Las Psitas Blvd. Pleasantn, CA T: F: Specify UHA Clinic Name: Address: TO DISCLOSE TO: at the fllwing address: (Persns/rganizatins authrized t receive the infrmatin) (Street) (City, State and Zip Cde)

2 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 2 f 6 SECTION C: Please describe the specific health infrmatin yu wuld like released by cmpleting the apprpriate infrmatin belw. Certain specific health infrmatin requires a separate indicatin frm yu in rder fr us t release that infrmatin, such as HIV test results, hereditary disrder test results, family planning services and certain mental health infrmatin. If yu wuld like this infrmatin released, yu will need t indicate separately in the bxes C.2, C.3, C.4, C.5 and C.6 belw. Yu must bth check the bx and initial next t the bx t authrize the release f the infrmatin described after the bx. C.1: General Health Infrmatin Release Please nte: if yu d nt check any f the bxes in the Sectins C.2, C.3, C.4, C.5 r C.6 belw and there is infrmatin in yur recrd as described in thse sectins, the infrmatin described in thse sectins will nt be included in the release if yu simply check the bxes in C.1. Hwever, we will include mental health recrds, except as nted in C.2. Check here and initial next t the bx if yu wuld like infrmatin related t specific dates f service released and nt the entire medical recrd. Indicate dates f service: Check here and initial next t the bx if yu wuld like t further describe the health infrmatin that yu wuld like released, and please prvide a descriptin: Check here and initial next t the bx if yu wuld like yur entire medical recrd released. Check here and initial next t the bx if yu wuld like yur Radilgy Film r Radilgy Cmpact Disk (CD) released. released. Check here and initial next t the bx if yu wuld like yur billing recrds r billing infrmatin C.2: Mental Health Infrmatin Check here and initial next t the bx if yu had inpatient psychiatric services prvided in the G2 r H2 hspital unit (SHC), r Legends Unit (Stanfrd Health Care-ValleyCare) and yu wuld like these recrds released. Please nte that the physician, licensed psychlgist, scial wrker r marriage/family therapist wh was in charge f the patient s care may deny release f yur infrmatin in limited circumstances. Check here and initial next t the bx if yu had utpatient psychiatric services prvided in the SHC Outpatient Psychiatric Clinic lcated at 401 Quarry Rad, Pal Alt, CA and yu wuld like these recrds released. Please nte that the physician, licensed psychlgist, scial wrker r marriage/family therapist wh was in charge f the patient s care may deny release f yur infrmatin in limited circumstances.

3 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 3 f 6 Check here and initial next t the bx if yu had utpatient psychiatric services prvided in the Outpatient Sprts Psychlgy Arrillaga lcated at 341 Galvez Street, Stanfrd, CA and yu wuld like these recrds released, please nte that the physician, licensed psychlgist, scial wrker r marriage/ family therapist wh was in charge f the patient s care may deny release f yur infrmatin in limited circumstances. IMPORTANT NOTE ABOUT MENTAL HEALTH INFORMATION: If yu received mental health services, such as psychiatric cnsult, when yu were an inpatient nt n the G2 r H2 (SHC), r Legends Unit (Stanfrd Health Care-ValleyCare) hspital inpatient psychiatric units r when yu were an utpatient in ne f the utpatient clinics ther than Outpatient Psychiatric Clinic at 401 Quarry Rad, Pal Alt, CA, r Sprts Psychlgy at Arrillaga, 341 Galvez Street, Stanfrd, CA, the mental health ntes in yur general recrd will be released when yu check the bxes in Sectin C.1. We will release all infrmatin in the general recrd as yu indicate in C.1, which may include mental health ntes if yu were seen in lcatins ther than the inpatient psychiatric unit r the utpatient psychiatric clinic. We will nt exclude r redact infrmatin that is included in the general recrd fr releases that yu authrize under Sectin C.1, including mental health ntes in the general recrd. We encurage yu t request a cpy f yur recrds and review them befre authrizing the release f the recrd. C.3: HIV Lab Test Results Check here and initial next t the bx if yu had HIV tests perfrmed and wuld like the HIV test results released. C.4: Hereditary Disrder Test Results Check here and initial next t the bx if yu had Hereditary Disrder tests perfrmed and yu wuld like the Hereditary Disrder test results released. Hereditary Tests include antenatal, nenatal, childhd and adult hereditary disrder screening recrds and/r related genetic cunseling services that were prvided in the Genetic Cunseling Department (all test results and recrds generated as part f the Hereditary Disrders Prgram). The release f this infrmatin may invlve the fllwing risks: re-disclsure by the recipient f Hereditary Disrder test results, lss r cmprmise f insurance benefits, r emplyment status. The release f this infrmatin may invlve the fllwing benefits: predeterminatin f genetic cnditins, crdinatin f care, treatment ptins. Yu shuld cnsult yur physician cncerning the risk and benefits f specific tests.

4 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 4 f 6 C.5: Family Planning Services Check here and initial next t the bx if yu had Califrnia Family Planning, Access, Care and Treatment (FPACT) services and wuld like this infrmatin released. FPACT services may include clinical services, drug and supply services r labratry services prvided at the Gyneclgy Clinic (GYN) r the Reprductive Endcrinlgy and Infertility Clinic (REI). If a minr has received family planning services, the release f these recrds requires authrizatin frm the minr. C.6: Nn-Treating Physician Access t Electrnic Medical Recrd Check here and initial next t the bx if yu authrize the fllwing physician(s) wh are nt invlved in yur treatment t access yur electrnic medical recrd and yu are nt requesting the release f yur printed medical recrd: SECTION D: Yu wuld like this infrmatin released in the fllwing frmat: (Select ne f the fllwing) Paper Cpy Encrypted CD/DVD Electrnic PDF File (Patient requests nly) Yu wuld like this infrmatin released via the fllwing methd: (Select ne f the fllwing) Mail Pick up in persn (Date): (Lcatin): Fax (Cntinued Care Requests Only) Prvide Fax number: Secure (Patient requests nly) Prvide address: MyHealth SECTION E: Please indicate the reasn yu wuld like yur health infrmatin released. Check here if yu are the patient and yu d nt want t prvide the reasn. Check here if the release is nt t the patient and prvide the reasn fr the release here:

5 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 5 f 6 SECTION F: EXPIRATION: This authrizatin will autmatically expire ne (1) year frm the date f executin unless a different end date is specified: (insert date) SECTION G: YOUR PRIVACY RIGHTS: Yu may refuse t sign this authrizatin. Yur refusal will nt affect yur ability t btain treatment r insurance payment r eligibility fr benefits. Yu may revke this authrizatin at any time, but yu must d s in writing and submit it t the fllwing address: Stanfrd Health Care,, MC6330, Stanfrd, CA Yur revcatin will take effect upn receipt, except t the extent that thers have acted in reliance upn this authrizatin. Yu have a right t receive a cpy f this authrizatin. Infrmatin disclsed pursuant t this authrizatin culd be re-disclsed by the recipient. Such redisclsure, in sme cases, may nt be prtected by State and Federal law. Please nte that if yu wish t impse restrictins n the recipient s use f the health infrmatin, yu must cntact the recipient directly. SECTION H: Cautins befre signing Yur health infrmatin that will be released as a result f yu signing this authrizatin culd be redisclsed by the recipient. If this ccurs, yur re-disclsed health infrmatin may n lnger be prtected by state r federal privacy law. We encurage yu t request a cpy f yur recrds and review them befre authrizing the release f the recrds t smene ther than yu. The release f this infrmatin may invlve certain risks, such as re-disclsure by the recipient, lss r cmprmise f insurance benefits, r emplyment status. If yu have questins abut this authrizatin frm r the release f yur health infrmatin, please cntact the Stanfrd Health Care (SHC) HIMS Department at , University HealthCare Alliance (UHA) HIMS Department at r Stanfrd Health Care-ValleyCare (SHC-VC) HIMS Department at , befre signing this frm.

6 Stanfrd Health Care (SHC) Stanfrd, CA Phne: HEALTH INFORMATION Page 6 f 6 SECTION I: Please sign and date this frm t authrize Stanfrd Health Care (SHC), University HealthCare Alliance (UHA) and/r Stanfrd Health Care-ValleyCare (SHC-VC) t release yur infrmatin as stated n this frm. Name f patient (please print): Name f legal representative signing this frm, if applicable (please print): Relatinship t patient: Address f patient r legal representative signing this frm (please print): Phne number f patient r legal representative signing this frm (please print): If yu are nt the patient and yu are signing this authrizatin frm, describe yur authrity t sign n behalf f the patient and PLEASE PROVIDE SUPPORTING LEGAL DOCUMENTATION: Signature f patient r legal representative: Date: A COPY OF THIS AUTHORIZATION FORM MUST BE GIVEN TO THE REQUESTOR SECTION J: If yu chse t return this frm via mail, please select ne f the fllwing facility mailing addresses: Stanfrd Health Care (SHC) Health Infrmatin Mgmt., MC 6330 Stanfrd, CA T: F: University HealthCare Alliance (UHA) Health Infrmatin Management Services 7999 Gateway Blvd. #200 Newark, CA T: F: Stanfrd Health Care-ValleyCare (SHC-VC) Health Infrmatin Management 1111 East Stanley Blvd. Livermre, CA T: F: Space intentinally left blank Patient/Representative Identificatin Verified: SHC/UHA/SHC-VC Staff Initials: Dept.: (Fr Office Use Only)