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District of Columbia Authorization for Release of Health Information Form

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District of Columbia Authorization for Release of Health Information Form
District of Columbia Authorization for Release of Health Information Form
A.2.1.c Standard Register HIPAA-
13N
Page 1 of 2 CopyMedical Records Copy Patient / Representative Effec. Date 9/20/13
JOHNS HOPKINS HOSPITALS
Johns Hopkins Hospital Johns Hopkins Bayview Medical Center
Howard County General Hospital Suburban Hospital
Sibley Memorial Hospital
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Complete all sections of this Authorization as appropriate to your request.
Patient Name: _____________________________________________ Birth Date: __________________
(first) (m. initial) (last)
Address: ____________________________________________ Phone #: _______________
(street address)
________________________________________________ Medical Record #: __________________
(city) (state) (zip code) (if known)
WHO
I hereby authorize ______________________________________________________________________to take the following action.
(fill in above the name of the Johns Hopkins hospital where your medical information is held)
ACTION REQUESTED (check one)
Provide a copy of My Health Information to me Let me look at My Health Information (I am not requesting a copy)
Release My Health Information to: Discuss My Health Information with: Obtain copies of My Health Information from:
________________________________________________________________________________________
(name of other person or entity)
_______________________________________________ ________________________________________
(street address) (city)
___________________________ ________________________ ___________________________________
(state) (zip code) (fax number)
(We cannot call before faxing.)
WHAT
For this Authorization, “My Health Information” means (check one or more):
Abstract (discharge summary, operative notes, Emergency Room Record Outpatient Record
clinic notes, diagnostic testing)
History & Physical Pathology Report
Billing Record Immunization Record Progress Note
Diagnostic Test/Results (lab, x-rays and Mental Health Records Other:________________________
other test results) Operative Report ________________________________
Discharge Summary
If I have initialed here (________), “My Health Information” includes Substance Abuse Records/Information.
If I have initialed here (________), this Authorization does NOT include records from other healthcare providers that are a part of my
Johns Hopkins records included in this request. (If this blank is not initialed, those records will be included.)
For the date(s) of service from: _______________ to _______________ (records will be provided for all service dates if left blank
)
(insert date(s) of service requested) (Note: Information from recent visits may not yet appear in the record.)
WHY
At my request For my healthcare / treatment For legal purposes For payment / insurance purposes
Other: _____________________________________________________________
District of Columbia Authorization for Release of Health Information Form
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