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Medical Record Request
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Medical Record Request
(To be initiated by the Patient or the Patient’s Legal Representative)
Patient Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Social Security Number
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
I hereby authorize the use and disclosure of individually identifiable health information relating to me, otherwise known as “protected health information” or “PHI” under a federal privacy law, as described below. I understand this authorization is voluntary. I consider a copy of this authorization to be valid as the original. I understand that if the organization authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
Person(s)/organization(s) providing the information:
*
Name of person(s)/organization(s) receiving the information
*
Address or person(s)/organization(s) receiving the information
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Specific description of information to be released including date(s) and type(s) of service:
*
Purpose for which information is to be used:
*
Treatment
Personal
Insurance
Follow-up
Legal
Other
If Other, please specify below
SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW
I specifically authorize the release of data and information relating to (please initial appropriate box below and hereby release Neurology Consultants of Nebraska, P.C. from all legal liability that might arise from the release of sensitive information protected by Title 42 of the Code of Federal Regulations.
*Substance Abuse (alcohol or drug abuse)
*Behavioral Health (except psychotherapy notes which require a specific authorization)
*HIV or other Sexually Transmitted Disease Related Informaitons (or AIDS related testing)
I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it, by writing to:
Neurology Consultants of Nebraska, P.C.
North Doctors Tower
4242 Farnam, Suite 500
Omaha, NE 68131
Without my written permission to revoke this authorization, it will automatically expire six months from the date of signature according to Nebraska Law.
If you desire a specific date (not to exceed six (6) months), or event upon which this authorization will expire, please specify:
I understand that I am entitled to a copy of this authorization form. I understand that I have the right to inspect or receive copies of my Protected Health Information (PHI) to be used and/or disclosed under this authorization, and that a fee for copies may be imposed by Neurology Consultants of Nebraska, P.C. or its designated Business Associate.
Recipient Please Note: This information may have been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation (42 C.F.R. Part 2) prohibits you from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.
Today's Date
*
Date Format: MM slash DD slash YYYY
Signature of Patient or Patient’s Legal Representative
*
Printed Name of Patient’s Legal Representative
*
Relationship of Legal Representative to Patient
*