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Embed code for: AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
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AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)
Mail to: 1947 Founders Circle
Attn: HIM Department
Wichita, KS 67206
Or fax to the following:
For Medical Records For Radiology Images For Dental Records
Phone: 316−613−4995 Phone: 316−689−9157 Phone: 316−613−4995
Fax: 316−613−5371 Fax: 316−689−9785 Fax: 316−689−9791
SECTION 1 − Demographic
Patient Name: _________________________________________________________________________ Date of Birth: _____________________________
Patient Name at time of treatment (if different): _______________________________________________ Telephone Number ________________________
Patient Street Adress: ___________________________________________________________________________________________________________
City: __________________________________________________________ State: _____________________________ Zip: ________________________
SECTION 2 − Identification of Entity/Persons/Class of Persons authorized to received PHI
Release Information FROM: Release Information TO:
Specify Facility and Address below, including phone/fax if known Specify Facility and Address below, including phone/fax if known
SECTION 3 − Type of access requested
SECTION 5 − PurposePurpose for use or disclosure: (check one)❏ Continued Care❏ Insurance/Disability❏ Litigation❏ Personal❏ Other (Specify)Specify dates of treatment: ______________________________________________________________________________________________________ Please describe the specific PHI you are requesting (check all that apply):
❏ Abstract ❏ Consult Report(s) ❏ Office Visit Notes ❏ Medication Record
❏ Lab Reports ❏ Imaging/Radiology Reports ❏ Last 2 years
❏ ONLY the following specified information: ________________________________________________________________________________________
I understand that requested information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about genetic testing, behavioral or mental health services and treatment of alcohol and drug abuse.
SECTION 4 − Expiration
Unless otherwise revoked, this Authorization shall expire upon this date: ________________________ or no later than one year from the date of this signed
SECTION 6 − Statment of Understanding
I understand that this authorization is voluntary and that I may refuse to sign it.
I understand that I may refuse to sign this Authorization. If I do not sign this form, my health care or payment for health care will not be affected.
I understand that once the disclosures authorized herein have been made, the information disclosed may be subject to re−disclosure by any recipient and no longer protected by federal privacy laws.
I understand that I have the right to inspect the health information I have authorized to be used or disclosed by this Authorization form.
I understand that I may revoke this Authorization at any time by delivering a written revocation to the Health Information Management Department at 1947 Founders Circle, Wichita, KS 67206
I understand that if I revoke this authorization, it will have no effect on disclosures already made in reliance on this Authorization
I authorize the use or disclosure of the Protected Health Information as described. I have received a copy of this form.
Signature of patient/legal representative: _________________________________________________________________ Date: ______________________
Printed name of representative:_____________________________________________ Representative’s authority to act: __________________________
(Must attach copy of legal documents validating authority)
Copy fees are set per the Kansas Department of Labor. Cost includes labor and supplies up to $18.97, plus $ .63 per page for the first 250 pages, and $.45 per page for every additional page. Actual postage or shipping costs also may be charged. Via Christi Clinic Copy Service is provided by HealthPort. If you have any questions or wish to check on the status of your request please contact HealthPort customer service at 1−800−367−1500. Please allow 12 business days for processing.
Authorization for Use or Disclosure of PHI
Via Christi Health
VAADMIN020 Rev. 02/2015 Page 1 of 1 316−613−4995
Copy fees are set per the Kansas Department of Labor. Cost includes labor and supplies up to $18.97, plus $ .63 per page for the first 250 pages, and $.45 per page for every additional page. Actual postage or shipping costs also may be charged. Via Christi Clinic Copy Service is provided by HealthPort.