Request for Family Medical Center, PA to Receive
Protected Health Information from Someone Else
Section I – Description of the Protected Health Information To Be Disclosed
Please specify what copies are being requested as well as the specific time frames.
Doctor's office Notes
Last 5 years
All
Lab & X-ray reports
Last 5 years
All
Records of hospital inpatient and outpatient services
Last 5 years
All
Records of other services
Last 5 years
All
Copies of records which you have had forwarded from other hospitals or Physicians
Last 5 years
All
Copies of administrative reports/letters
Last 5 years
All
Copies of everything in the chart
Last 5 years
All
Include copies of records pertaining to mental health, alcoholism, HIV, developmental disabilities, drug abuse, and sexually transmitted diseases
Last 5 years
All
Other Records:
If the choices above do not allow you to adequately describe the information you want disclosed,
please describe your request here:
** Your records will be part of Family Medical Center, PA designated record set
Section II – Individual Authorized to Make the Disclosure
Please specify whom is authorized to disclosure the requested protected health information.
Section III – Identity of Individual to Receive Disclosed Information
Please send the requested protected health information to
(Check One)
:
Medical Records Department
Family Medical Center, P.A.
811 S. E. Second Street, Suite A
Little Falls, Minnesota 56345-3558
Medical Records Department
Community Medical Center
200 South First Avenue
Pierz, Minnesota 56364
Section IV – Purpose for the Disclosure
At the request of the individual
Other:
If you feel it is needed so we can honor your wishes,
please provide an explanation of the purposes for disclosing the information here:
Section V – Expiration
This authorization expires in 30 days
This authorization expires on:
This authorization expires with the following event:
Section VI – Required Statements
You have a right to revoke this authorization at any time as explained in the clinic's
Notice of Privacy Practices.
You have the right to receive your own copy of the Notice of Privacy Practices.
The covered entity whom you are authorizing to disclose protected health information may not condition treatment, payment, enrollment or eligibility for benefits in the future on whether or not you sign or revoke this authorization.
You must understand that there is the potential for information disclosed pursuant to this authorization to be the subject of redisclosure by the recipient and no longer protected by the federal HIPAA regulation.
Section VII – Signature
I agree that a photocopy of this authorization may be accepted in lieu of the original.
Patient Name:
Date of Birth:
Name of requestor (if not the patient):
Relationship to Patient:
Signature
Date
