Mid-America Heart & Lung Surgeons


INFORMATION REQUEST – PATIENT AUTHORIZATION

 
All sections of this authorization form MUST be completed to be valid in accordance with 42 CFR Parts 160 and 164
I request my records from
Mid-America Heart & Lung Surgeons
I request my records to be sent to
What records do you want?




Covering the period of health care from

Purpose for requesting information (optional)



How would you like your records delivered?


By signing this authorization form, I understand that
  • Requests for copies of medical records and/or non-document material may be subject to copying fees.
  • PHI may include records relating to mental health care, communicable diseases, HIV/AIDS, and/or treatment of alcohol/drug abuse.
  • I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to the Health Information Management Department. Revocation will not apply to information that has already been released in response to this authorization.
  • Unless otherwise revoked, this authorization will expire on the following date/event/condition: If I fail to specify an expiration date/event/condition, this authorization will expire one year from the date signed.
  • Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization.
  • Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.
Patient / Authorized Representative’s Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Witness’ Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
If signed by a patient’s authorized representative, supporting legal documentation must accompany this authorization form
Please upload the documentation before submitting your form (to upload more than one item, hold the “Shift” key and press the items you are planning to upload)
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