Search results with tag "Medical record number"
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT …
healthy.kaiserpermanente.orgPatient Name:_____ Medical Record Number: _____ Birth Date: _____ Email: _____ Do not use for patient copies of or access to their medical records. ... and a note stating to whom your information was disclosed will be included in your medical record. A copy of the original authorization is valid. You have a right to a copy of this completed ...
Content of the Patient Record: Inpatient, Outpatient, and ...
myresource.phoenix.eduThe patient record is a valuable tool that documents care and treatment of the patient. It is essential that every report in the patient record contain patient identification, which consists of the patient’s name and some other piece of identifying information such as medical record number or date of birth. Every
Patient Authorization to Disclose, Release and/or Obtain ...
depts.washington.eduPatient Authorization to Disclose, Release or Obtain Protected Health Information. Item #1 (Patient Information): The name, birthdate, phone number and Medical Record Number (if known) of the patient. Item #2 (Purpose): indicate any and all purposes for disclosure.
AUTHORIZATION FOR USE, REQUEST AND DISCLOSURE OF …
www.harrishealth.orgMedical Record Number or City/State: _____ Social Security Number: _____ Zip: _____ ... This authorization will automatically expire in 180 days from the date of the signature unless: (1) an expiration event or date is provided below; or (2) “none” has ... Name of Patient (or Personal Representative) (Print) ...
Medical Record Number: (for internal purposes)
www.emoryhealthcare.orgE If you are requesting your medical information via e-mail, please be sure that you have provided us with an accurate e-mail address. E-mail and attachments will be sent to you in an encrypted format with instructions on how you retrieve the information.
Medical Record Number: Patient Name: AUTHORIZATION …
www.uclahealth.orgAUTHORIZATION FOR RELEASE OF (PHI) PROTECTED HEALTH INFORMATION SSN (Last Four Digits UCLA Form #30910 Rev. (02/14) Page 1 of 2
Medical Record Number: (for internal purposes) - Atlanta, …
www.emoryhealthcare.orginformation related to the treatment of physical and/or mental illness, chemical dependency or alcohol abuse, or testing or treatment of any communicable or infectious disease such as acquired immunodeficiency syndrome (AIDS), Immunodeficiency Syndrome