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UMass Memorial-HealthAlliance Hospital

60 Hospital Road
Leominster, MA 01453-8004 / *RL0004* /

MR#: ______

RL0004 / Correspondence

Authorization for the Disclosure of Personal Health Information

I hereby authorize UMass Memorial - HealthAlliance Hospital, their employees, and/or agents, to release information from the medical record of:
Patient Name: First: MI: Last: Suffix: Sex: r M r F
Please Print / (Sr. Jr. I, II,) / Check one
Street: Floor/Apt#:
City: State: Zip Code:
Phone #: Date of Birth:
Please Release To: / r / Self / r / Physician (no charge if sent directly to physician’s office by HIS staff) / r / Organization
(Ins. Co., Lawyer, etc.)
Name:
Street: PO Box/Suite #:
City: State: Zip Code:
Phone #: Fax #:
I understand that my health record may include information related to my mental health, drug/alcohol abuse, sexual assault, sexually transmitted diseases, abortion, genetic testing, HIV/AIDS, domestic violence, or other information I may consider sensitive. If there are exclusions, I have indicated them in writing below:
Listed Exclusions (if any):
COPY FEE: Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies. At no time, will the cost-based fees, exceed Massachusetts law (MGL Chapter 111; Section 70).
Definitions of content released when requesting the following visit/encounter types listed below:
Abstract: Includes: Diagnostic Tests (Labs, Rads, Echos, PFT, etc.) Problem List, Medication Reconciliation List, Allergies and all Dictated Reports)
Entire Encounter/Visit: Includes: All documentation within a specific encounter/visit date.
REQUEST TYPE - I request copies of the following records: / Date(s) of Service:
q  Itemized Hospital Bill(s) / Date(s) of Service:
q  Emergency or Urgent Care / q Abstract / q Entire Encounter/Visit / Date(s) of Service:
q  Laboratory/Radiology / q Type: ______ / Date(s) of Service:
q  Outpatient Clinics
(ex: Audiology, Cardiac Rehab, Pulm Rehab, PT, OT, etc.) / q Type: ______ / Date(s) of Service:
q  Fitchburg Family Practice (FFP) / q Abstract / q Entire Encounter/Visit / Date(s) of Service:
q  Same Day Surgery / q Abstract / q Entire Encounter/Visit / Date(s) of Service:
q  Hospital Stay
(ex: Inpatient, Observation (OBV) or Obstetrics (OBS) / q Abstract / q Entire Encounter/Visit / Date(s) of Service:
Definition of content released when requesting entire medical record:
Abstract: Includes key elements of all documentation related to all encounters/visits within the last 20 years.
Entire Medical Record: Includes any and all documentation related to all encounters/visits within the last 20 years.
q  Abstract of Medical Record / q Entire Medical Record
HIS Confirm with Requestor / Specific Date Range: ______
Please Continue On Reverse Side
Patient Name: First: ______MI: ______Last:______
I understand the following:
·  This authorization is voluntary.
·  Per the Notice of Information, I have the right to inspect or request copies of my medical records. Arrangements must be made to inspect my medical record on-site; please contact the Health Information Services Department at 978-466-2834.
·  Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost-based fee for producing and mailing the copies. At no time, will the cost-based fees, exceed Massachusetts law (MGL Chapter 111; Section 70).
·  Any disclosure carries the potential for unauthorized re-disclosure. I release HealthAlliance from any legal liability that may arise from the disclosure or re-disclosure of this information.
·  I have the right to revoke the authorization at any time by presenting a written request to the Health Information Services Department (Medical Records) at the address below. Revocation will not apply to information that has already been released in response to this authorization. Revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
Expiration of Authorization: Unless otherwise revoked in writing, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization shall be valid for not more than ninety (90) days from the date of the signature below, except when Federal and/or State regulations specify otherwise.
The Reason for Request is: (check one)
q  Continuing Medical TX / r Self- Personal Use / q  Attorney/Legal / r School
q  Insurance Company / r Disability (Requires documentation) / q  Pre-Employment / r Other: ______
Processing Information
·  Non-Billable requests, totaling ten (10) pages or less, will be processed by HealthAlliance Release of Information staff on a first come first serve basis, during our normal business hours, at no charge to the patient.
·  Non-Billable requests (eleven (11) pages or more) will be processed by BACTES, our Release of Information vendor and sent directly to the designated recipient.
·  Billable requests will be processed by BACTES, our Release of Information vendor. BACTES will send an invoice to the recipient and once it is paid, the records will be sent.
Requested Format
r Paper Copies - Mail / r  Paper Copies – Pick Up* / r  CD ** - Pick Up Only
* Pick up records in HIS/HIM Department on Basement Level of HealthAlliance Hospital
** HIS Staff–Potential Meaningful Use Request. Is request an OBV or INPT? If yes, complete Form # NSIO 1758 and process accordingly.
If you would like to have someone other than you (the patient/requestor) to pick up the requested medical records, please provide their name and relationship to you/patient: Please instruct them to bring a picture ID.
Name: ______Relationship to Patient: ______
I have completed all sections of this form. I have read and understand the above statements and authorize the disclosure of the information requested on the reverse side of this form.
______
Signature of Patient / Parent / Legal Guardian / ______
Date / ______
Relationship to Patient
Please mail or fax your request to: / HealthAlliance Hospital
Health Information Services Department
Attn: Release of Information
60 Hospital Road
Leominster, MA 01453
Phone (978) 466-2857 or 2834 Fax (978) 466-2831 (Requests ONLY)
Questions regarding your request?
BACTES Contact Information / Patients: 978-922-0016 or Toll Free: 877-584-1222
Attorneys/Insurance Companies: 800-560-3800
All Other Requestors
Original - Medical Record
Form # NSIO 1110 Revision Date: 07-07-2017 / SPANISH version NSIO 1277 / CTP: Legal Documentation