Request for Access to / Authorization for Use and Disclosure of Protected Health Information

ST. ANTHONY TELEHEALTH Request for Access to / Authorization for Use and Disclosure of Protected Health Information (Please fill out completely) PATIENT NAME: ______LAST FIRST MI MAIDEN OR OTHER NAME DATE OF BIRTH:______- ______- ______SSN: ______MEDICAL RECORD #______* ADDRESS: ______CITY______STATE_____ ZIP ______

DAY PHONE: ______EVENING PHONE: ______

I hereby authorize St. Anthony Hospital to share/disclose my protected health information as indicated below to:  Mail to:  Hold for pick up by: NAME/ORGANIZATION______RELATIONSHIP (family, attorney, physician, etc):______

ADDRESS: ______CITY ______STATE ______ZIP______

PHONE: ______FAX: ______INFORMATION TO BE RELEASED (please include dates of service):  Entire medical record (excluding psychotherapy notes)  History & Physical Exam ______I specifically authorize the release of information relating to:  Lab Reports ______ Substance abuse (including alcohol/drug abuse)  Pathology Report ______ Psychotherapy Notes  EKG Report ______HIV related information (AIDS related testing)  Discharge Summary ______ X .  Phy Orders/Progress Notes ______SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE  X-Ray Reports/Films ______ Operative Report ______ Consultation Report ______ Other (specify content and date): ______PURPOSE OF DISCLOSURE:  Consultation  Changing physicians  Insurance/Workers’ Compensation  School  At request of individual  Research  Legal (specify): ______ Other (specify): ______ For purpose access (specify):  Copy  Inspection  Summary ACKNOWLEDGEMENT OF UNDERSTANDING: Initial each line: ___I understand protected health information is information that identifies me. The purpose of this authorization is to allow the St. Anthony Telehealth/St. Anthony Hospital to share my protected health information. ___I authorize the St. Anthony Telehealth/St. Anthony Hospital as set forth above, to share my protected health information for reasons in addition to those already permitted by law. ___I understand this authorization is valid for  12 months from the date signed below or other (insert date or event): ______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 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 of disclosure that 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 if the person/organization authorized to receive my protected health information is not a health plan or health care provider, privacy regulations may no longer protect the information. ___ I understand I may inspect or obtain a copy of the protected health information shared under this authorization by sending a written request to the address listed at the bottom of the form. ___ I understand that I may be required to pay the cost of preparing and mailing copies, supervising my inspection, or preparing a summary except for uses and disclosures for the purpose of treatment, payment, and operations. ($1.00 1st page, $0.50 for each additional page)  If checked and initialed, I authorize the St. Anthony Telehealth/ St. Anthony Hospital to share my protected health information for the purpose of market. I understand the St. Anthony Telehealth/St. Anthony Hospital may receive either direct or indirect compensation for sharing my information in this case. Initial here: ______I UNDERSTAND THAT MY MEDICAL INFORMATION MAY INDICATE THAT I HAVE A COMMUNICABLE OR NONCOMMUNICABLE DISEASE WHICH MAY INDLUDE, BUT IS NOT LIMITED TO DISEASES SUCH AS HEPATITIS, SYPHILLIS, GONORRHEA OR THE HUMAN IMMUNDOFICIENCY VIRUS, ALSO KNOWN AS ACQUIRED IMMUNINE DEFICIENCY SYNDROM (AIDS). I FURTHER UNDERSTAND THAT MY MEDICAL INFORMATION MAY INDICATE I HAVE OR HAVE BEEN TREATED FOR PSYCHOLOGICAL OR PSYCHIATRIC CONDITIONS OR SUBSTANCE ABUSE.

Patient/Legal Representative Signature: ______DATE: ______RELATIONSHIP: ______*Must have copy of your valid photo ID

Records Received by: ______DATE: ______ID VERIFIED______

Auth for Use Disclosure of PHI RL 3-2013 Telehealth 4-2013