If you have questions about your health insurance or your hospital bill, a Patient Financial Advocate will be happy to answer your questions by telephone, or if you request it, will come to your room while you’re still in the hospital. Make it known whether you clearly understand a contemplated course of action and what is expected of you. Please call the site you are requesting records from for further details on submitting the form. You and your nurse will discuss your departure time. If you have questions about accessing your medical records, please contact our Health Information Management Office: UHS Release of Information Dept. Please maintain these instructions and refer to them when you leave as they have important information regarding your post-hospital care. 185 0 obj
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Please return the completed form to:Disclosures team . If you choose to use the television or telephone, a small daily charge will apply. Pharmacies have computers to check for interactions and allergies, but when your doctor gives you samples, this important check may be missed! {B�U�A�j��� �ɜ��,]1�i_�-��'��$缟�ﺎClrIqn}���>95$�63FNqU,���ioC"�m�Ht���d@#0�G��-+�X��Mǁ Medical Records Release Form We have made it easy to obtain a copy of your medical records. The physical record is the property of UHS. UT does not recognize E-Signatures as valid signature for medical record releases. You can talk directly to a registered nurse by calling Nurse Direct, 8:30 a.m. to 6:30 p.m., seven days a week. While you are in the hospital, you may not need the same medications. If you would like additional information, please ask for a copy of the pamphlet “Deciding About Health Care — A Guide for Patients and Families.”. Know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation. If you’re having ambulatory surgery at Chenango Memorial Hospital or Delaware Valley Hospital, you should report to the hospital’s Admissions/Registration office at the time your physician instructs you to. MyChart users can complete a Release of Information request by logging into MyChart, selecting Other Resources and then selecting Request My Medical Records. �W�UV���'��v���QI�iq��H������c@����� Identify a caregiver who will be included in your discharge planning and sharing or post-discharge care information or instruction. Understand and use these rights. (WMH, BGH, and physician practices) • To Release my Medical Information to: The name or other identification of the person to whom University Health When you get ready to go home, have the doctor or nurse go over each medication with you and a family member. Privacy while in the hospital and confidentiality of all information and records regarding your care. Users are asked to be courteous to other patients and visitors by keeping the volume of their device muted or by using headphones. The attached form must be mailed or faxed to: University Health and Counseling Services Northeastern University Forsyth Building, Suite 135 360 Huntington Avenue Boston, MA 02115-5000. Tel enquiries: 023 8120 4885. Also list your medication and food allergies, and any over-the-counter medications, vitamins, nutritional supplements or herbal products that you take regularly. UHS has medication cards that can be used to document your prescriptions and over-the-counter products. Southampton. If your doctor gives you samples, make sure that he/ she checks to be sure there are no interactions with your other medications. Please call the clinic or hospital where you received care and ask to speak with someone in the Medical Records department. Social workers provide psychological and social assessments and counseling, and coordinate referrals for post-discharge follow-up, nursing home placement, home care nursing, delivery of home medical equipment and end of life care. Mailing or faxing the completed form to the following address: CiOX Health 8501 Excelsior Dr. Madison, WI 53717 Fax: (608) 203-4580; Option 2 . In deciding whether or not to participate, you have the right to a full explanation. The patient does not automatically receive a copy of his/her medical record upon discharge from the hospital. The financial advocates are experienced with most insurance coverages and options, including Medicare and Medicaid. If you are currently seeing an UHS doctor and he/she refers you to another UHS doctor, your doctor’s office will transfer the necessary records for you. If you can’t find the form you seek in the list below, please contact us at medicalrecords@nd.edu or at 574-631-7497. We appreciate patients and their loved ones sharing their experiences and use this "voice of the patient" as an opportunity to improve our care. Your doctors, nurses and pharmacists work hard to keep you healthy, but you are also responsible. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. If you’re admitted to the hospital by your physician, you’ll receive a phone call to let you know when the hospital can admit you. s0�r�n�m@����s+�V�K�P�0 p��
Make a list of medications you are taking now. Student Vaccine Exemption. Sometimes your health care journey will take you from the doctor’s office to a hospital or a specialty department within UHS. UHS Chenango Memorial Hospital and UHS Delaware Valley Hospital allow inpatients to bring small electrical appliances with them to their inpatient room. Step 1: Print your date of birth, social security number, and maiden name. You can make an appointment to view your medical records at no charge. Forms; Forms Chances are, we have the form you’re looking for. You have to ask your pharmacists, doctors, and nurses about your medications, and you have to expect answers. Submit your completed paper authorization form to Record Connect by emailing a copy to dupage. Copies of your medical records can be provided to healthcare professionals for continuing care. 607-865-2180. There is no charge for use of the telephone or television in inpatient rooms. If you prefer to complete a paper authorization form, please download and print the Authorization for Release of Health Information Form. A medical record is considered private and confidential. We know how exhausting medical record requests can be, from demands on staff time to delays in claims processing. Please note: For security purposes, we do not process requests for medical records via e-mail. In addition to your rights as a patient, you also have responsibility to: Here at UHS, we want our patients to feel safe, respected, listened to and cared for in a way that fosters confidence and trust in UHS. UHS can release your medical records to you or another person or entity. They feel a lot alike when you grab quickly. Consent for Medical Treatment I voluntarily consent to be treated. Receive considerate and respectful care in a clean and safe environment free of unnecessary restraints.
Provide, to the best of your knowledge, accurate and complete information concerning present complaints, past illnesses, hospitalizations, medications and other matters relating to your health. Meningococcal Information & Waiver *Information about Global Waivers at HUHS. Tell your doctor you want to know the names of the medications you will be receiving while in the hospi-tal and the reason you are taking them. Persons sixteen years of age or older may document their consent to donate their organs, eyes and/or tissues, upon their death, by enrolling in the NYS Donate Life Registry or by documenting their authorization for organ and/or tissue donation in writing in a number of ways (such as a health care proxy, will, donor card, or other signed paper). Be informed of the name and position of the doctor who will be in charge of your care in the hospital. If you need any of these services, please ask a staff member. Pathway’s telephone number is 888.891.6523. With this information in place, your pharmacist can help protect you against harmful drug interactions, duplicate medications, and other potential problems. Please write to hhf@uhs.rochester.edu to request the form. These plans start with information collected on admission and are evaluated for you by nursing staff, your physician and case manager or social worker throughout your hospital stay. Be considerate of the rights of other patients and hospital personnel, and assist in the control of noise, smoking and the number of visitors. General information lines are listed below: Your confidentiality is our priority. Many drug names look alike when written poorly; knowing the purpose helps you and the pharmacist double check the pre-scription. release Information from my medical records as described above. Language and Hearing Interpreter Services, New York State Department of Health’s website, A photo ID, such as a driver’s license or state ID, Your insurance/Medicare card and any required insurance forms, A list of prescription and nonprescription medications and vitamins, minerals and herbal supplements you’re taking, including the dosage and frequency; (please ask your physician beforehand if you should bring any of your medications to the hospital), Copies of any advance directives about your health care that you’ve already completed, Names and phone numbers of family members or friends to contact in an emergency, Written list of past hospitalizations, illnesses, surgeries and allergies, Personal toiletries such as shampoo, toothbrush, toothpaste, denture cream and face creams. 607-763-6015, Option 2, UHS Chenango Memorial Hospital Medical Records from other Health Care Providers ... Form 5800713 Authorization for Release of Protected Health Information. n���>����(����N�F裺�J/&����'��'����o��qa�*&
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A! Any time that your medications change, update your list too. Click here to download the patient rights booklet. You can do this by telephone using one of the numbers listed above, or you can submit your comment online. Wireless access is free and no passwords are required, but users must provide their own wireless devices. Email enquiries: disclosures@uhs.nhs.uk. Report any perceived or identified safety issues related to your care or physical environment to your physician(s) or other healthcare provider. Or, fill out a Medical Record Authorization form. To properly complete this form, fill out all sections. %PDF-1.4
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a written authorization for health providers to release information to the patient as well as someone other than the patient If you do not have this experience, our patient relations representatives and patient advocates are here to assist you. Please share your concerns, suggestions or compliments with us. status@ recordconnectinc. h�bbd```b``���@$�w�Q"���I��P�rL>��A$� �� D2�Ȱ�`s> D����{"�`6X/H�1wX�%B���W��>��X�L���}�� �
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)qECi�/�6/�WΗP�8˙3g9�,vk����L�����n���gG�Z�Y?˙3'9���L����{���ͬa4T8긂�5j{�ʀ��f���}x�����j9y��8�;PC��G�]%H�C�W" Additional forms will be brought to you for your signature after you’ve been assigned a room. Medical Records Authorization Form. After discharge, the above charges will appear directly on your home telephone bill as “Hosp Tel Chg.” VISA, MasterCard and Discover are also accepted. Find out all you can about your conditions and the medication(s) you are taking — including over-the-counter medications. Copies of records will not be faxed but will be mailed or can be picked up at Health Services during normal operating hours. All rights reserved. Mail your HIPAA Compliant Authorization form to: University Health Attention: Release of Information Medical Records Department/MS-26-2 4502 Medical Drive San Antonio, TX 78229-4496. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file. Medical records may be released by fax, mail, secure email or be picked up from the health center after the patient has signed a Medical Records Release Form (pdf). There is no fee for transferring your medical records directly to another health care provider. Be respectful of your personal property and that of other persons and of the hospital. Authorization to release protected health information: To authorize release of your protected health information, please download and fill out the Authorization Form below. The hospital charges a fee of 75¢ per page for copies. They will be happy to assist you with the process for transferring records to a specific doctor’s office. They may not know about medications that another doctor has prescribed for you. Please visit the center website for directions and parking information, as well as details on how to prepare for your surgery. Report perceived risks in your care and unexpected changes in your condition to your physician(s) or other healthcare providers. UHS keeps your medical records confidential, however they're readily available when you need to share information with your health care team. UHS will provide an interpreter for any patient or family who doesn’t speak English. Please note that UHS retains records for 10 years past last date of service. However, patients at UHS Delaware Valley Hospital must have these items inspected by a staff member prior to their use; please speak with your nurse. Make known your wishes in regard to anatomical gifts. Pathway’s telephone number is 888-891-6523. To request a copy of your substance use medical records for yourself or to be sent to another healthcare provider, an insurance company, attorney, school or other organization, complete an Authorization Form for Release of Medical Records and Information. Wilson Medical Center Patient Relations Office: Binghamton General Hospital Patient Relations Office: Chenango Memorial Hospital Patient Advocate Office: Delaware Valley Hospital Quality Improvement Office. Medical Records: 619-543-6704; Medical Records Office Locations. Authorization for your health care provider to release your medical records to Harvard University Health Services. I acknowledge that no guarantees have been made as to the result of treatments or examination at… (607) 337-4295. 03 15 18 MU Patient Authorization ngb This authorization is HIPAA compliant pursuant to 45 CFR 164.508. This process can take up to 30 days. Follow hospital rules and regulations affecting patient care and conduct. Health records has a period of 30 days to respond to your request at which time you will be notified whether the change has been made or not. You privacy is important. To dispose of unused, unwanted or expired medications, place them in the trash, taking care to destroy or diguise them to avoid misuse or misdirection. Send them home with your other medications either won ’ t be effective or could make you.. Staff will be in charge of your plan of care no charge will not be denied copy... 'S care prior to being copied and released to the New York State Department! 'Re readily available when you need any of these services, please ask staff! Or, fill out a medical record is the property of the telephone, a small daily charge apply. Admissions/Registration is located: if you prefer to complete a paper authorization form to Disclosures. Services, please make any necessary arrangements to Leave the hospital can charge a reasonable fee will notify health. 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