Such forms are available at the Marketing & Public Affairs web page of the UW Health intranet. University of Washington 1959 N.E. UW Medicine will disclose only the minimum amount of PHI necessary to accomplish the purpose of a given request for the use and disclosure of patient information for research. REQUEST AMENDMENT OF MED RECORD . Authorization to Release Protected Health Information to a Third Party - MC0072-01 Instructions: This form is to be used by a patient or legal representative to authorize the release of information to a third party (other than a family member or friend) such as an insurance company, employer, or … Find a doctor or book an appointment online. h�bbd```b``�"g�I�2,^&=@$�N0 �5��`RL~��H� r�'�dl�63D��uA�Y��{������'H(C&���q�7� �OK Please use the following options to reach us to provide services to you: (608) 263-6030, Select Option 5 Item #3 (Records to be released from): identify the holder of records to be released are for services provided. Each office has an individual process to authorize users to view student information. CANARY - PATIENT A medical release form can only be completed by a patient who is sound in mind and body. The Family Educational Rights and Privacy Act (FERPA), is a federal law that governs the use of, and limits access to student educational records. The University of Washington provides professional liability coverage to Pathology through a self-insurance program pursuant to RCW 28B.20.250 through RCW 28B.20.255, which is equivalent to or exceeds limits of at least $1,000,000 per occurrence/claim and $3,000,000 annual aggregate. Box 356500 Seattle, WA 98195-6500 INFORMATION • NOTE that if an authorization is needed for disclosure of a patient’s medical information for purposes of fundraising or marketing, a separate form is required. Release of Patient Information Each UW Medicine entity has a department that is responsible for appropriately disclosing patient information. Chapter 70.02 RCW sets regulations regarding health care information access and disclosure. Please complete these forms and have them handy to review with your provider. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. This authorization will also allow these individuals to obtain information about your tuition charges over the phone, by email or in-person. PLACE PATIENT LABEL HERE UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center Office Phone: 314-273-0453 Fax: 844.868.1435 • The revocation will not apply to information already released in response to this authorization. Adult Preventative Care 2018; New Patient Packet; Integrative Medicine Intake Form; Consent to Treat a Minor; Release of Information; FMLA Disability Information Worksheet; Snohomish Family Medicine. If you need a copy of a medical record from UW Medical Center, Harborview Medical Center, or the Neighborhood Clinics, please visit their website or contact Release of Information directly at 206-744-9000 or fax 206-744-9997. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or • Request detailed information about your earnings or employment history. General UW Medicine. Item #2 (Purpose): indicate any and all purposes for disclosure. Mail: Release of Information 400 S. 43. rd. It may include data elements from outside sources that are embedded in tables and documents. UH2078 REV JAN 20 . You may also deliver the completed form in person to the department from which you would like to request information. Below you’ll find forms that may be applicable to your primary or specialty care appointment or procedure. %%EOF 4240 Duncan Ave., Suite 301 . Email: Recordsrequest@valleymed.org. You can also use this form to request medical records from Hall Health/UW Medicine. Do not use this form to: • Request the release of medical records on behalf of a minor child. St. Louis, MO 63110 . UW Medicine . Medical Release. Get help. Fayetteville, AR 72703. For Valley Medical Center patient forms, please visit the VMC website. All UW Medicine workforce members are encouraged to refer requestors of patient information to their entity department to process requests for disclosure of patient information. Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington. Advance Directives: Advance directives are legal documents used to communicate your preferences about future health care. This webpage is designed to be a reference for parents and family members who are interested in learning more about access to academ… UW Medicine is a premier healthcare system that integrates comprehensive patient care and nationally ranked research for over 300 medical clinics. Employee Health Clinic. Instead, complete and mail form SSA-7050-F4. 5. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit. Questionnaires Patient’s Ability to Sign. Contact UW Medicine’s Medical Records Department at 206.744.9000. h�b```f``����� �A��2�,M7������X�gK v�a�h ��10�/��@, e`8��Ƥ���%����!���9̿���|iHb`���p�L��.�#�Ja��� ;�̏p�H20=5Ҍ@�` �� Please be aware that other authorizations may handle these protected conditions differently. PHQ-9 Form; GAD-7 Form; Medical Records. 395 0 obj <>stream Authorization to Release Medical Records; Request digital copies of radiology images; Contact: Medical Records Phone: 920.784.2482 Fax: 920.593.3029. It may be obtained from multiple paper-based or electronic-based forms (as applicable). Provided are links to the forms for you to review prior to your initial appointment. Marysville Family Medicine. Pacific St. Please complete these forms and have them handy to discuss with your provider. RCW 70.02.010(37) defines the “reasonable fee” that may be charged for duplicating or searching the record. 0 Radiology Images Phone: 206.860.5496, Option 3 Fax: 206.860.4539 *Note: Requests can take up to 15 business days to process. New Patient Forms – Outpatient Psychiatry Clinic Release of Information Authorization Forms Authorization to Use, Disclose and Release Protected Health Information Complete this form to authorize Providence to disclose a copy of your protected health information to someone other than yourself. UW Medicine eCare is a free, secure and convenient way to access many types of personal health information in your inpatient or outpatient medical records, including test results, medical history, medications, immunizations and more. endstream endobj startxref Telehealth Patient Info Sheet and Zoom User Guide If you have a reason to think to patient isn’t mentally capable of making the decision to release medical information, or if they have a physical condition (like intense pain) that might influence their decision-making abilities, you can’t accept the release form. %PDF-1.6 %���� UW Medicine IT Services - Identity & Access Management (IAM) Mission: UW Medicine Information Technology Services’ Identity & Access Management (IAM) provides UW Medicine Account administration, support, and subject matter expertise regarding clinical and business systems in accordance with University of Washington and UW Medicine policies and State and Federal regulations. COVID-19 UPDATE: During the COVID-19 virus pandemic, where we are practicing physical distancing to reduce the risk of community spread of the virus, the Health Information Management team will not be taking walk-in requests for records at the 8501 Excelsior Drive location.. endstream endobj 363 0 obj <. Students are able to authorize online access to their statement for up to five people by logging on to MyUW and completing the online Information Release Authorization. Complete and print the Authorization for Exchange of Verbal and Written Information form (pdf) Mail the completed form to the following address: UW Health Health Information Management Attention: Release of Information 8501 Excelsior Dr., Room 101 Madison, WI 53717; Or fax the completed form to (608) 262-6663 There may be a $25 fee. Health Forms Here is a collection of helpful, downloadable health forms. Use this form to request a replacement for a Financial Aid/Refund check. Washington University Health Information—Release Services . Forms: Health Services Release of Information; Counseling Services Release of Information; Allergy Injection Agreement; No Show Appeal Form Complete the Release of Information form and submit it by mail, fax, or email to UW Medicine’s Medical Records Department (see contact information above). Please note: The UW Health authorization does authorize release of records containing psychiatric diagnoses or treatment, alcohol or drug abuse information, or HIV or AIDS information, unless you specify any exceptions on the line above the signature line. Medical Records Release Please be aware that we are NOT the office that releases medical records. Forms Mailing address: University Health & Counseling Services 800 W. Main Street Whitewater, WI 53190 UHCS Medical Records FAX: 262-472-5608 UHCS Counseling Records FAX: 262-472-1435. Street P.O. If you have any questions concerning the cancellation process, call the Health Information Management (Medical Record) Department (425) 339-5426 extension 2171 or 2321. Please read and complete the entire form in order for UW Medicine to process this request . Aid Check Replacement. Box 50010 Renton, WA 98058. Provided are links to forms for patients who are seeing a provider at the UW Outpatient Psychiatry Clinic. ; Imaging Records Release: Use this form if you’d like your diagnostic imaging data and reports released to another medical facility. Form to request medical records or share medical information Read more about Release of Medical Information (ROI) and find the form you’ll need to give a parent, partner or other family member access to your medical record. 362 0 obj <> endobj Provided are links to the forms that you may need for your appointment. Purposes for disclosure to access the student 's account for information regarding tuition and loans Patient... 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