UPMC Authorization for Release of Protected Health Information free printable template

G My decision to revoke the Authorization does not apply to any release of my records that may have taken place prior to the date of my revocation of the Authorization may be responsible for payment of the claim. g UPMC cannot require me to sign the Authorization in order to receive treatment. g In accordance with 4 Pa Code 255. 5 b Drug Alcohol treatment information to be released to judges probation or parole officers insurance company health or hospital plan or government officials shall be...restricted to the following 1 Whether the client is or is not in treatment 2 The prognosis of the client 3 The nature of the program 4 A brief description of the progress of the client 5 A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. g I am entitled to a copy of this completed Authorization form. Please return the completed authorization using one of the methods below Mail to PSD Health Information Management Department 3600...Meyran Avenue Suite 9029 Pittsburgh PA 15213 412-647-8586 Email HIMROI upmc.edu Please call 412-864-0854 if you require assistance with completing this form.. If applicable specify other expiration date/event here Date of Signature Signature of Patient 14 years of age or older may authorize release of inpatient mental health information or 18 years of age or older for outpatient mental health information. A minor may authorize release of Drug Alcohol treatment information. Signature of...Authorized Representative Appropriate paperwork required c Parent or Legal Guardian ORAL AUTHORIZATION for persons physically unable to sign NOT Applicable to HIV related Information or Drug Alcohol Treatment Information I witness that the patient understood the nature of this release and freely gave their oral authorization. Two witnesses are required Date Witness 1 A photostatic copy of this authorization shall be considered as valid and effective as the original. Please note that emails will...be sent via a secure and encrypted electronic system. Power of Attorney Additional Patients Rights and Responsibilities g A disclosure statement as required by law will accompany all records released. g Release of my records will be for the purpose stated on this form. Only those items checked off or listed will be released. g Although applicable law may prohibit re-disclosure of these records I understand that it is possible that the facility/person that receives the records may re-disclose the...information therefore 1 UPMC and its staff/employees have no responsibilty or liability as a result of an redisclosure and 2 such information would no longer be protected by the Privacy Rule. For UPMC / Highmark Transition of Care Only Authorization for Release of Protected Health Information I authorize and/or the following UPMC hospital s Name of Physician Office or Clinic c East c Magee-Womens c McKeesport c Mercy c Passavant Cranberry c Shadyside c Presbyterian/Montefiore c St* Margaret c...South Side to release information from the record of Patient Name / Last 4 digits of SSN Birth Date Patient s Email Address City Street Address State Zip Code as described below to Facility/Person to Receive Records Phone c Self and Physician Send records via secured email to Records are requested for the purpose of Facility s Email Address Fax c c Self only Physician only c Transfer of Care Parts 1 and 2 must be completed to properly identify the records to be released* 1.