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
Patient Name
Date of Birth
Name at Time of Treatment
(if different)
Address
City
State
Zip
Email Address
Phone
I request my records from
Mid-America Heart & Lung Surgeons
I request my records to be sent to
Name
Email Address
Address
City
State
Zip
Phone
Fax
(healthcare provider only)
What records do you want?
Office/Clinic Visits
Discharge Summary
Operative Report
Detailed Billing
Other
Covering the period of health care from
All Past, Present and Future Encounters/Visits
Specific Dates
From
To
Purpose for requesting information (optional)
Legal
Personal
Insurance
Continuation of Care
How would you like your records delivered?
Paper
Secure electronic delivery (will use above listed email)
Other
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.
Date
Time
Authorized Representative Name
Relationship to patient
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.
Date
Time
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)