HTML Preview Personal Medical Records Release Form page number 1.
SSM Health “Request for Access to/Authorization for Use and Disclosure of Protected Health Information”
Name of SSM Health Entity maintaining the information that is subject to this Authorization: __________________________________________
PATIENT NAME:________________________________________________________________________________________________________
LAST FIRST MI Maiden or Other Name
DATE OF BIRTH:_____-_____-_____ FORMER NAME:_________________________ MEDICAL RECORD #___________________
MO DAY YR
ADDRESS:________________________________________________ CITY:_________________________STATE:____ZIP:________________
DAY PHONE:________________________ EVENING PHONE:_____________________________
Type of access requested: Inspection Hard Copy Electronic Copy (only available if SSM Health maintains the requested information electronically)
I Hereby Authorize: To Disclose My Protected Health Information To:
METHOD OF DELIVERY OF RECORDS (please select one):
Mail Hold for pick up by:
Electronic (records will be provided on a CD and mailed to your residence)
INFORMATION TO BE RELEASED:
DATES:
Discharge Summary _________________
History & Physical Exam _________________
Progress Notes _________________
Lab Reports _________________
X-Ray Reports _________________
Medication Records _________________
Detailed Bill _________________
Other (specify content and dates):__________________________________________________________________________________________________
PURPOSE OF DISCLOSURE:
Changing physicians Consultation Insurance/Workers’ Compensation School Research At request of individual
Legal (specify): _________________________________________________________________________________________________
Other (specify): _________________________________________________________________________________________________
For personal access (specify): Copy Inspection Summary
ACKNOWLEDGEMENT OF UNDERSTANDING:
I understand the expiration date of this authorization is ______________ at end of research study; not applicable for ongoing research.
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to
the extent action has already been taken in reliance upon it.
I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by Federal or
State privacy regulations.
By authorizing this use or disclosure of information, there will be no conditions placed on my health care or payment for my health care.
I understand that if I am being requested to authorize a use or disclosure that, upon request, I will get a copy of this form after I sign it.
I understand my request will be acted upon within 30 days. If I am not provided access or information cannot be supplied, I understand I will be notified, and have the
right to request review of any denial of access other than those made in accordance with applicable law.
I understand that I may be required to pay the cost of creating paper copies or electronic media, mailing copies, supervising my inspection, or preparing a summary
except for uses and disclosures for the purpose of treatment, payment, and operations.
SSM Health believes that the only way to avoid third party interception of information sent through e-mail is to send such information by encrypted e-mail. Despite
this warning about the risk that my protected health information could be read/intercepted by a third party if it is not sent by encrypted e-mail, I request SSM Health to
send an electronic copy (if available) of the requested information by unencrypted e-mail.
I acknowledge and understand the terms of this Request for Access to/Authorization for Use and Disclosure of Protected Health Information.
Patient/Legal Representative Signature:_______________________________________________ DATE:_________________
Relationship: _______________________________________________
Records Received by:______________________________________________ DATE:____________ ID VERIFIED:____________________
NAME
Relationship
ADDRESS
CITY, STATE & ZIP
PHONE
FAX
NAME
ADDRESS
CITY, STATE & ZIP
PHONE
FAX
I specifically authorize the release of information relating to:
Substance abuse (including alcohol/drug abuse)
Mental health or behavioral health
HIV related information (AIDS related testing)
X____________________________________________________________
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE