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New York Medical Records Release Form 2

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This form is provided by Beth Israel Medical Center to authorize the disclosure or release of one person's protected health information.

New York Medical Records Release Form 2
New York Medical Records Release Form 2
BETH ISRAEL MEDICAL CENTER 2011
MEDICAL RECORDS RELEASE FORM/
PATIENT ACCESS OF MEDICAL INFORMATION
M.R.# _____________________
PATIENT NAME__________________________DATE OF BIRTH__________________________S.S.#_______________________
STREET, APT #___________________________________________________________________________________________________
CITY, STATE, ZIP CODE________________________________________________TELEPHONE #______________________________
1. I hereby authorize the Medical Records Department staff at Beth Israel Medical Center to release information from my medical record to
(If self please indicate below):
2. NAME______________________________________________________________________________________________________
ADDRESS___________________________________________________________________________________________________
CITY, STATE, ZIP CODE______________________________________________________________________________________
For the purpose of (please check one)
_____Continued Treatment _____Legal Review _____Insurance purpose
_____Personal review of information _____Other (please specify)__________________________________________
3. I limit the information to be released to the following items: (Please check specific items)
_____Discharge Summary _____Consultation _____Diagnostic test (e.g. Lab, X-ray, Radiology)
(please specify)___________________
_____Operative Note _____Pathology
_____Other (please specify)__________________
_____Emergency Department Record _____Outpatient Record
(please specify)_____________________________
Covering records from on or about (Date)_____________________________________to (Date)___________________________________
CONFIDENTIAL INFORMATION
4. If the requested portion of the record contains information pertaining to mental health or drug or alcohol treatment or contains HIV related
information, you must specifically authorize the release of such information by initialing one or both of the following:
________ I understand that if my record contains information concerning mental health and/or drug and alcohol treatment, such
information will be released pursuant to this authorization.
________ I understand that if my record contains confidential HIV related information, such information will be released pursuant to this
authorization form. Confidential HIV related information is any information indicating that a person had an HIV related test, or has HIV
infection, HIV related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
5. I know I do not have to allow release of HIV related information and that I can change my mind at any time before it is released. If I experience
discrimination because of release of HIV confidential information, I can call the NYS Division of Human Rights at (212) 480-2493 and/or the
NYC Commission of Human Rights at (212) 306-7450.
6. This authorization will automatically expire within six months from the date of signature. I understand that I have a right to revoke this
authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the
Medical Records Department at Beth Israel Medical Center. I understand that the revocation will not apply to information that has already been
released in response to this authorization.
7. I also understand that I have the right to refuse to sign this authorization. Your health care, the payment for your heath care, and your health care
benefits will not be affected if you do not sign this form. You also have a right to receive a copy of this form after you have signed it.
8. I also understand that in an effort to prevent unauthorized re-disclosure Beth Israel Medical Center attaches a notice when sending out records
that states, “re-disclosure is prohibited”. However, the potential for an unauthorized re-disclosure may not be protected by federal
confidentiality rules.
9. I also understand that in order to process this request to reproduce medical record information on a timely basis, Beth Israel Medical Center, in
which I am requesting information from, may utilize a photocopy service and my signature authorizes the release of information to such
photocopy service for the purpose of satisfying this request.
_______________________________________________________ ________________________________________
(Signature of Patient/ Representative/ or Legal Guardian) (Date)
________________________________________
(If other than patient, relationship to patient) (Notary/ Witness)
New York Medical Records Release Form 2