Fenway Health Authorization of Disclosure for Protected ... · 4)Fenway Health will not...
Transcript of Fenway Health Authorization of Disclosure for Protected ... · 4)Fenway Health will not...
Fenway Health Authorization of Disclosure for Protected Health Information
Patient Name:____________________________
Name Used:____________________(If different from above)
Date of Birth:__________________________Patient Address:________________________________________________________________________
I give permission to release my protected health information and medical records
Records of (circle selection)Pap SmearMammogram Colon Cancer ScreeningImagingImmunizationsPathology ReportsER/Hospital Discharge Reports Radiographs
Treatment received between these dates: From__________ To___________
Other:__________________
All medical records
To share medical records with another provider Transfer ALL care away from Fenway HealthTo allow ongoing bi-directional communication about this patient's care with an outside provider Other (please specify):_________________________________________________
This authorization is valid for this request only and will not be honored for any subsequent requests. This authorization for disclosure (unless expressly revoked earlier) will remain valid for one year from the date signed below. I understand that I may revoke this authorization at any time by making a request in writing to the Privacy Officer of Fenway Health. I understand that substance abuse records are protected by 42 CFR, Part 2 and may not be disclosed without my specific authorizations. Those same federal regulations also protect any substance abuse records from re-disclosure by any third party. I hereby acknowledge that I have read, or have had read to me, and fully understand the above statements as they apply to me, and do voluntarily consent to disclosure.
X_____________________________________________________________________________________________
Patient's signature, or if authorized agent signature, please specify relationship to patient Date
Mail/Fax to: Fenway Health Att Medical Records; 1340 Boylston St., Boston MA 02215 Phone: 617-927-6191 Fax: 617-425-5713 email: [email protected]
1) From:______________________________________ Name/Title of Provider
Phone Number__________________________
Fax Number____________________________
Address_______________________________
______________________________________
3) I give permission to share my medical records:
2) To:_____________________________________ Name/Title of Recipient
Phone Number________________________
Fax Number__________________________
Address______________________________
_____________________________________
4) Fenway Health will not release/request these types of healthinformation unless we have your explicit permission.
Please initial next to each type of record to be released
Abortion Care______________Alcohol or Drug Abuse Treatment ___________ Behavioral Health Information written by your medical providers__________ Behavioral Health Information written by your psychiatrist, therapist, mental health clinician, or social worker___________Genetic Test Information __________HIV/AIDS Test Results or related care _________ Intimate Partner Violence Counseling _________ Sexually Transmitted Diseases __________ Sexual Violence Counseling ___________
5) Reason(s) for release:
Phone Number:_________________________