Request for Information Form - Stonewall Jackson Memorial Hospital

TELEPHONE: (304) 269-8069 FAX: (304) 269-8148PATIENT AUTHORIZATION TO DISCLOSE HEALTH INFORMATIONPatient Name _________________________________________________________________________Address_________________________________________________________________________Medical Record No. _____________________________ Date of Birth ____________________1 I authorize the use or disclosure of the above-named individual’s health information, asdescribed below.The following individuals or organizations are authorized to make the disclosure: StonewallJackson Memorial Hospital, 230 Hospital Plaza, Weston, WV 26452.2 The type and amount of information to be used or disclosed is as follows (check off theappropriate item(s), and include other information, where indicated):Discharge summary History and physical Operative reportPathology report Progress notes Physician ordersNursing notesEKG __________________________________________(date)Laboratory results from ______________________(date) to _________________________(date)X-ray and/or imaging reports from ______________________ (date) to ________________(date)Consultation reports from (Please supply doctors’ names) _________________________________Emergency Department RecordOther outpatient testing (specify with dates) ____________________________________________Other (please describe) __________________________________________________________________________________________________________________________________________________________________________________________________________________________3 I understand that the information in my health record may includeinformation relating to any sexually transmitted disease, acquiredimmunodeficiency syndrome (AIDS), or human immunodeficiencyvirus (HIV). It may also include information about behavioral ormental health services and treatment for alcohol and drug abuse.4 This information may be disclosed to, and used by, the following individuals or organizations:Name __________________________________Address __________________________________5 This information is being disclosed for the following purpose(s):Medical Legal Personal InsuranceOther (Specify) ____________________________________________________________SJMH 11/1/11

6 I understand that SJMH will charge a fee of $0.40 cents per page for copying of my medicalrecord.7 I understand that I have the right to revoke this authorization at any time. I understand that inorder to revoke this authorization, I must do so in writing and present my written revocation tothe Information Management Department at Stonewall Jackson Memorial Hospital, 230 HospitalPlaza, Weston, WV 26452. I understand that the revocation will not apply to information thathas already been released in response to this authorization. I understand that the revocationwill not apply to my insurance company when the law provides my insurer with the right tocontest a claim under my policy.8 If I fail to specify an expiration date, event or condition, this authorization will expire six monthsfrom the date of signature unless otherwise revoked.9 I understand that once the information is disclosed pursuant to this authorization, it may beredisclosed by the recipient and the information may not be protected by federal privacyregulations.10 If I have questions about disclosure of my health information, I can contact the Privacy Officer at(304) 269-8501 or the Director of Information Management at (304) 269-8088.11 I understand I may be given a copy of this authorization form after signing.SIGNATURES:Patient/Legal Representative: _______________________________________ Date: ______________If signed by legal representative, relationship to patient:______________________________________Signature of Witness: ______________________________________________ Date: ______________SJMH211/1/11