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    Confidential Information

    Uploaded by

    Jose Hanson
    This document is an authorization form for the release of medical information from St. Luke's-Roosevelt Hospital Center. It allows the patient to indicate what medical records they are authorizing to be released, to whom, and for what purpose. The patient must also authorize the release of any confidential information like mental health, substance abuse, or HIV-related documents. The authorization will expire after six months unless revoked earlier in writing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Confidential Information

    Uploaded by

    Jose Hanson
    134 views1 page
    This document is an authorization form for the release of medical information from St. Luke's-Roosevelt Hospital Center. It allows the patient to indicate what medical records they are authorizing to be released, to whom, and for what purpose. The patient must also authorize the release of any confidential information like mental health, substance abuse, or HIV-related documents. The authorization will expire after six months unless revoked earlier in writing.

    Original Description:

    mrf

    Original Title

    Mrf

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    This document is an authorization form for the release of medical information from St. Luke's-Roosevelt Hospital Center. It allows the patient to indicate what medical records they are authorizing to be released, to whom, and for what purpose. The patient must also authorize the release of any confidential information like mental health, substance abuse, or HIV-related documents. The authorization will expire after six months unless revoked earlier in writing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    134 views1 page

    Confidential Information

    Uploaded by

    Jose Hanson
    This document is an authorization form for the release of medical information from St. Luke's-Roosevelt Hospital Center. It allows the patient to indicate what medical records they are authorizing to be released, to whom, and for what purpose. The patient must also authorize the release of any confidential information like mental health, substance abuse, or HIV-related documents. The authorization will expire after six months unless revoked earlier in writing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ST.

    LUKES-ROOSEVELT HOSPITAL CENTER


    AUTHORIZATION FOR RELEASE/PATIENT ACCESS OF MEDICAL INFORMATION
    M.R. # _____________________
    PATIENT NAME__________________________DATE OF BIRTH__________________________S.S. #_______________________
    STREET, APT #___________________________________________________________________________________________________
    CITY, STATE, ZIP CODE________________________________________________TELEPHONE #______________________________
    1.

    I hereby authorize the Medical Records Department staff at St. Lukes-Roosevelt Hospital Center to release information from my medical record
    to (If self please indicate below):

    2.

    NAME______________________________________________________________________________________________________
    ADDRESS___________________________________________________________________________________________________
    CITY, STATE, ZIP CODE______________________________________________________________________________________
    For the purpose of (please check one)

    3.

    _____Continued Treatment

    _____Legal Review

    _____Insurance purpose

    _____Personal review of information

    _____Other (please specify) __________________________________________

    I limit the information to be released to the following items: (Please check specific items)
    _____Discharge Summary

    _____Consultation

    _____Diagnostic test (e.g. Lab, X-ray, Radiology)


    (Please specify)___________________

    _____Operative Note

    _____Pathology

    _____Emergency Department Record

    _____Other (please specify) __________________


    _____Outpatient Record
    (Please specify)_____________________________

    Covering records from on or about (Date)_____________________________________to (Date)___________________________________


    4.

    CONFIDENTIAL INFORMATION
    If the requested portion of the record contains information pertaining to mental health or drug or alcohol treatment or contains HIV related
    information, you must specifically authorize the release of such information by initialing one or both of the following:
    ________ I understand that if my record contains information concerning mental health and/or drug and alcohol treatment, such
    information will be released pursuant to this authorization.
    ________ I understand that if my record contains confidential HIV related information, such information will be released pursuant to this
    authorization form. Confidential HIV related information is any information indicating that a person had an HIV related test, or has HIV
    infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.

    5.

    I know I do not have to allow release of HIV related information and that I can change my mind at any time before it is released. If I experience
    discrimination because of release of HIV confidential information, I can call the NYS Division of Human Rights at (212) 480-2493 and/or the
    NYC Commission of Human Rights at (212) 306-7450.

    6.

    This authorization will automatically expire within six months from the date of signature. I understand that I have a right to revoke this
    authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the
    Medical Records Department at St. Lukes-Roosevelt Hospital Center. I understand that the revocation will not apply to information that has
    already been released in response to this authorization.

    7.

    I also understand that I have the right to refuse to sign this authorization. Your health care, the payment for your heath care, and your health care
    benefits will not be affected if you do not sign this form. You also have a right to receive a copy of this form after you have signed it.

    8.

    I also understand that in an effort to prevent unauthorized re-disclosure St. Lukes-Roosevelt Hospital Center attaches a notice when sending out
    records that states, re-disclosure is prohibited. However, the potential for an unauthorized re-disclosure may not be protected by federal
    confidentiality rules.

    9.

    I also understand that in order to process this request to reproduce medical record information on a timely basis, St. Lukes-Roosevelt Hospital
    Center, in which I am requesting information from, may utilize a photocopy service and my signature authorizes the release of information to
    such photocopy service for the purpose of satisfying this request.

    _______________________________________________________
    (Signature of Patient/ Representative/ or Legal Guardian)

    ________________________________________
    (Date)

    (If other than patient, relationship to patient)

    ________________________________________
    (Notary/ Witness)

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