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3. Date
of Birth: Enter month,
day and year of patient’s birth. This is used to identify the
correct patient record.
4. I
hereby authorize _____________:
This can be a name of any health care provider or facility (
i.e. Dr. Jones or ADC. If only one Doctor name is listed then
only that provider’s information will be released.) If
information is being requested from another health care provider
outside of ADC and you would like this information to be sent to
ADC, then include complete mailing address and mail to that
provider. ADC does not mail the form.
5. Date
of Services: Time frame
of selected information to be released. Can be one day or a
range of dates or years. If no time frame is given, then the
most recent two years of information will be released.
6. Description
of Information to be released:
This is to guide us to select the proper documents to fulfill
the request.
7. Select
types of information to be released:
Select all that apply. If your ADC record contains information
from another provider, please check the other box and
enter “outside records” and the name of the facility. Please
understand that we will only have copies and they may not be
complete.
8. This
information may be disclosed to and used by the following
organization: Enter a
complete name of person or facility, along with a mailing
address to receive the information, a telephone number is
helpful. If records are needed by more than one person/facility,
a separate request is required. If records are for yourself,
please write your complete name and address. Include a contact
telephone number.
9.
Description of the purpose of the use and/or disclosure:
Reason for the request. Check all that apply.
10. Expiration
Date: Please enter an
expiration date or event. If left blank, the authorization will
automatically expire in 180 days. If a date is entered that is
the same day the authorization is signed, the authorization is
only valid for one day. Do not use “indefinite” please use a
specific future date or event (2050, until received, one year
from today etc.)
11. Signature
of Patient or Patient Representative:
the patient or representative must sign the form.
12. Date:
Enter in date authorization is signed.
13. Printed
Name of Patient or Patient Representative:
this is for verification purposes.
14. Relationship
to Patient: If you are
a patient representative, please indicate your relationship to
the patient. Except in the case of parents, we require a copy of
the documentation appointing you as person with authorized
access.
15. Legal
Authority: Legal
guardian etc. We require a copy of the documentation appointing
you as person with authorized access.
There is a
$15.00 fee payable at the time the request is made for personal
copies or to transfer records to another health care provider. .
If your request is more than 100 pages in length, an additional
per page fee of $.50 per page will be required. Please make
checks payable to ChartOne. Please contact HIM 901-4153
if you have any questions. Patient identification will be
required when picking up copies of records made with advance
arrangements. We have by law fifteen (15) days to complete the
request. You may mail your request to Release of Information,
The Austin Diagnostic Clinic, 12221 N Mopac Expressway, Austin
TX 78758-2483. |
