Medical Records Request Form his form is intended for use by patients requesting a copy of their medical records for their personal use T or for delivery to another physician participating in their care. If you are not satisfied with the hospital’s response, you can complain to the New York State Health Department. s0�r�n�m@����s+�V�K�P�0 p�� Substance Use Medical Records. Share Everywhere; Access your Health Records No more than $10 in cash to purchase magazines, etc. Copies of your medical records can be provided to healthcare professionals for continuing care. Our nursing staff and a care manager or social worker will assist you with discharge plans. At Admissions, you’ll be asked to complete and sign forms that permit us to care for you, to bill your insurance carrier on your behalf, and to release (or not) information about your admission. Ö�?R����2��롽Sm�T� �m��N��l�T��U�*[Aڡn. Refuse treatment and be told what effect this may have on your health. 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. Other Forms. Once received health records will notify the health care provider of your request. 9-19 Rose Road. Now UnitedHealthcare is making it easier. These will be useful in giving credit to the staff at the hospital that has requested the medical form. When you come to the hospital, bring a list of the medications, nutritional supplements, vitamins, over-the-counter medications and herbal medications you are taking at home. One charge covers use of both the television and telephone. Transfer from a UHS doctor to another doctor outside of UHS: For the purposes of this section, and notwithstanding Chapter 159, Occupations Code, or any other law, a request for the medical records of a deceased person or a person who is incompetent shall be deemed to be valid if accompanied by an authorization in the form required by Section 74.052 signed by a parent, spouse, or adult child of the deceased or incompetent person. Medical Records: 619-543-6704; Medical Records Office Locations. Tell your doctor you want the purpose for the medi-cation written on the prescription. Please maintain these instructions and refer to them when you leave as they have important information regarding your post-hospital care. If UHS needs information from another facility, for example Lourdes, we would write Lourdes Step 1: Print your date of birth, social security number, and maiden name. Medical Record Release Form (from Non-Guthrie Providers) eGuthrie. You can also fax your request at 210-358-5936. For patient convenience, this office is available for immediate walk in bill payment. Some long acting medications are absorbed too quickly when chewed. SO14. 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’re admitted directly from your physician’s office, please report to Admissions unless your physician directs you otherwise. That way, if anyone tells you anything different, you’ll know to ask questions, which might prevent an error. A medical record is considered private and confidential. 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. Obtain a copy of your medical record for which the hospital can charge a reasonable fee. Make a list of medications you are taking now. This may include following the instructions of nurses and advanced practice providers as they carry out your physician's orders and as they enforce the applicable hospital rules and regulations. endstream endobj startxref To obtain copies of your medical records, please contact the clinic or hospital where you received care and ask to speak with the Medical Records department. Do not hesitate to stop in or call on our financial advocates. *State laws require reporting of certain communicable diseases to the Health Department, such as AIDS, Tuberculosis, Syphilis, all … Many drug names look alike when written poorly; knowing the purpose helps you and the pharmacist double check the pre-scription. Free and secure access to your UHS healthcare team and services. 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. A list of all UHS clinics and hospitals and their phone numbers is available online. Instructions for activating the television and making local and long-distance calls are provided in the patient handbook in your hospital room. n���>����(����N�F裺�J/&����'��'����o��qa�*& ?��(&��̭�+i��t�|Ҡ�.�U�'O�'����1�C�1�L�WzT�68�r�eYа��(�:�[�Ӡ� "[��RJ��b� ���]��5���������4�]���{Z��a\�h�x7��x��cwo� A! United Health Services, Inc. and the members of the UHS System neither are affiliated with, sponsored, endorsed nor approved by, nor otherwise associated with, Universal Health Services, Inc. (NYSE: UHS), UHS of Delaware, Inc. nor their affiliates, which can be found at www.uhsinc.com. 185 0 obj <>/Filter/FlateDecode/ID[<098027C9F4CE4194B574D5C7BCA068ED><6D5E20A7276A4E4C99A20A37816D4DBD>]/Index[152 70]/Info 151 0 R/Length 133/Prev 185394/Root 153 0 R/Size 222/Type/XRef/W[1 3 1]>>stream Sub­mit your com­plet­ed paper autho­riza­tion form to Record Con­nect by email­ing a copy to dupage. If you do not have this experience, our patient relations representatives and patient advocates are here to assist you. 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. Forms; Forms Chances are, we have the form you’re looking for. Form Updated on January 10, 2019 Notice UHS and many other organizations and individuals such as physicians, hospitals and health plans are required by law to keep your health information confidential. General information lines are listed below: Your confidentiality is our priority. Each clinic, hospital and specialty department maintains confidential medical records of its patients. Find out all you can about your conditions and the medication(s) you are taking — including over-the-counter medications. UHS Wilson Medical Center and UHS Binghamton General Hospital. Copies of your medical records are available to you upon request. 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. For inpatient stays of more than 24 hours, a $7 daily fee will be charged for days 1 through 14 of a patient’s stay. Ask your pharmacist for help if you have trouble selecting the right product. Through CaringBridge you can set up a website that is your personal and private journal, guestbook and photo album. The UHS staff will be happy to assist you. UHS is proud to sponsor CaringBridge. Remember...medication error prevention is a shared responsibility. If it doesn’t look like what you usually take, ask why. Expect answers...it’s your life and your health! Your doctor and your nurse will give you instructions about post-hospital care. Please contact the UHS clinic or hospital where you would like the records to be sent. When you buy over-the-counter medications, read the label carefully, because the medication may contain ingredients you do not want or should not take. Privacy while in the hospital and confidentiality of all information and records regarding your care. 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. All forms must have an original signature before the request can be processed. The form must be complete to include: • I Request and Authorize: The name or other specific identification of the person who is authorized to make the requested use or disclosure to include date of birth, address and phone number. Norwich, NY 13815 Once you know what time you can expect to be released, please make any necessary arrangements to leave the hospital. Partners Trust Bank has an ATM inside the cafeteria at. UHS has medication cards that can be used to document your prescriptions and over-the-counter products. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge. Our social work team assists patients and families in coping with the stresses that accompany illness and hospitalization. If you have questions about your diet, activities or other matters, or aren’t comfortable with your discharge instructions, please be sure to ask at this time. You can make an appointment to view your medical records at no charge. We want this to be as convenient as possible. The hospital charges a fee of 75¢ per page for copies. status@ recordconnectinc. Release of Medical Record Tel enquiries: 023 8120 4885. release Information from my medical records as described above. Review your medical record without charge. There is no fee for transferring your medical records directly to another health care provider. If you are a parent or legal guardian of a minor child, in most cases you will be able to access the child’s health care information if you provide proper identification and sign a consent form. Follow your treatment plan established by the practitioner primarily responsible for your care. However, while you enjoy television programming or use your patient phone in any of our facilities, please respect the rights of others and keep the volume low. They feel a lot alike when you grab quickly. You also have the right to designate an individual to give this consent for you if you are too ill to do so. Your pharmacist can be your partner in preventing medication errors. The more information you have, the better able you are to prevent errors and take care of yourself. 607-763-6015, Option 2, UHS Chenango Memorial Hospital 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. Moreover, the form ensures that only those who have the patients consent are given access to his/her medical information. Please note that UHS retains records for 10 years past last date of service. Be respectful of your personal property and that of other persons and of the hospital. What you learn will help protect you. The health care proxy is available from the hospital. If you choose to use the television or telephone, a small daily charge will apply. Please contact the clinic or hospital where you received care and ask to speak with the Medical Records department. Copies of your medical records are available to you upon request. The patient financial advocate’s office is located in the hospital’s main lobby and is open from 7:30 a.m. – 12:30 p.m. and 1:30p p.m. – 4:30 p.m. Health Record Release - Medical Services . Ask your doctor to explain what is written on any prescription including the drug name and how often you should take it. Family Medical Leave Act (FMLA) - Family Member Application . a written authorization for health providers to release information to the patient as well as someone other than the patient This may include routine diagnostic, radiology and laboratory procedures and medication administration by my healthcare provider, his/her assistants or his/her consignees as may be necessary in his/her judgment. NO PHOTOGRAPHS OR VIDEO MAY BE TAKEN of any patient or staff member without his or her explicit permission. UHS keeps your medical records confidential, however they're readily available when you need to share information with your health care team. Mixing prescription medications with an undesirable substance, such as used coffee grounds or kitty litter, and putting them in containers such as empty cans, or sealable bags will further ensure the medications are not diverted. com or by fax to 1−630−873−8797. They may not know about medications that another doctor has prescribed for you. Medical Records Release Form We have made it easy to obtain a copy of your medical records. The information contained in your medical records belongs to you, and you are entitled to access that information. Share your CaringBridge website with your friends and family. (WMH, BGH, and physician practices) In deciding whether or not to participate, you have the right to a full explanation. Release of Medical Information Form (PDF) Complete this if you want UHS to release your medical information to another provider, or if you need copies of your records. Please write to hhf@uhs.rochester.edu to request the form. Don't store medication in the bathroom medicine cabinet or in direct sunlight. Southampton. Your doctors, nurses and pharmacists work hard to keep you healthy, but you are also responsible. Patient Financial Advocates are ready to assist all patients with any financial questions and payment issues that may arise. This service is provided by Pathway Solutions, LLC 3840 East Robinson Rd, Suite 140, Amherst, NY 14228. Challenge an unexpected bill through the Independent Dispute Resolution process. The form can be mailed in/emailed/faxed or dropped off in person. Then when you take it to the pharmacy, you can double check the information on the label. Please return the completed form to:Disclosures team . Sometimes your health care journey will take you from the doctor’s office to a hospital or a specialty department within UHS. They happen in hospitals, in pharmacies,or even at home. Accept responsibility for your actions should you refuse treatment or do not follow your physician’s instructions. Family Medical Leave Act (FMLA) - Employee Application . Understand and use these rights. The purpose of the aforementioned release form is limiting who health care providers can share medical information with. Group Trip Request for Travel Health . The hospital charges a fee of 75¢ per page for copies. 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. You will need to complete the UHS Authorization for Release of Medical Information Form before your records can be released by UHS. Incident and Injury Report . Don’t chew, crush or break capsules or tablets unless instructed. 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. Visitors may not enter any UHS facility with a weapon of any kind. For more information, contact Project HEAR, UHS Home Care TTHH, at 607.763.8952. If you have questions about accessing your medical records, please contact our Health Information Management Office: UHS Release of  Information Dept. Please be aware that you may incur a cost with the copies of your medical records. If you’re having ambulatory surgery at the new Ambulatory Surgery Center at Wilson Place, you should report there at the time your physician instructs you to. While you are in the hospital, you may not need the same medications. This free and easy to use service helps to connect you to family and friends during a health crisis or long-term hospital stay. Keep appointments, and when you are unable to do so for any reason, notify the responsible physician or the hospital. Please note: For security purposes, we do not process requests for medical records via e-mail. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file. A federal law, HIPPA was enacted to protect the medical records of a patient and ensure his/her privacy. Participate in decisions regarding your medical care, including the planning and implementation of your plan of care. Keep medications separate from pets’ medications or household chemicals. The purpose of the HIPPA release form is restricting access to patient information. Click here to download the patient guide for UHS Binghamton General Hospital and UHS Wilson Medical Center. Our new EMR Access program transforms how we request and receive medical records — a program that can help you lighten your administrative costs, see faster turnaround times of your appeals and free up your staff to focus on patient care. Be informed of the name and position of the doctor who will be in charge of your care in the hospital. Health Record Release - Occupational Health Services . If you would like additional information, please ask for a copy of the pamphlet “Deciding About Health Care — A Guide for Patients and Families.”. Ask to speak with the Medical Records department. Medical Records Authorization Form. h�b``�g``�����x�*`b�$1y(f`d�g��i1hoHh�s�$K�1A�,���9�5��]��v3~b`22� You can also pick up this form at all University Health locations in the Medical Records Department. Follow hospital rules and regulations affecting patient care and conduct. You cannot be denied a copy solely because you cannot afford to pay. Please send all requests for records with a physically signed authorization form. The law allows for exceptions and typically limits the amount of information that can be released under special circumstances. Medical records must be completed by all physicians involved in the patient's care prior to being copied and released to the patient. 03 15 18 MU Patient Authorization ngb This authorization is HIPAA compliant pursuant to 45 CFR 164.508. If you pre­fer to com­plete a paper autho­riza­tion form, please down­load and print the Autho­riza­tion for Release of Health Infor­ma­tion Form. I acknowledge that no guarantees have been made as to the result of treatments or examination at… All other medical records requests must be received in writing using one of the forms listed below: Release medical Information from UHS: Authorization for Release Complete this if you want UHS to release your medical information to another provider, or if you need copies of your records. Legal representatives can also gain access to patients' records. Student medical services are confidential. Remind your nurse and doctor if you have allergies. If you have a question, concern or complaint about your care, please speak with your nurse or the nurse manager of the unit you’re on. Do not complete this form for potential future requests for records. Receive treatment without discrimination as to race, color, religion, sex, gender identity, national origin, disability, sexual orientation, source of payment, or age. Fax: 617-373-2601. 607-865-2180. Report perceived risks in your care and unexpected changes in your condition to your physician(s) or other healthcare providers. Exchange Scholar UHS Enrollment Form . Copies of records will not be faxed but will be mailed or can be picked up at Health Services during normal operating hours. Or, fill out a Medical Record Authorization form. Copies of your medical records can be provided to healthcare professionals for continuing care. Television and Telephone: Inpatient rooms at all four UHS Hospitals are equipped with televisions and telephones; details about each appear below. If for any reason you do not understand or you need help, the hospital MUST provide assistance, including an interpreter. 221 0 obj <>stream You are welcome to request copies of your medical records at any time. Complain without fear of reprisals about the care and services you are receiving and to have the hospital respond to you and if you request it, a written response. Before you leave the pharmacy, your pharmacist should give you printed information about the medication and make sure that you understand the answers to your questions. To give liquid medication, use only the cup or other measuring device that came with the medication. Transfer from a UHS doctor to another UHS doctor: This service is provided by Pathway Solutions, LLC 3840 East Robinson Rd, Suite 140, Amherst, NY 14228. Your whole family can benefit from these programs. Make known your wishes in regard to anatomical gifts. 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. Refuse to take part in research. A sign language interpreter is also available if needed. Patient Financial Advocate 152 0 obj <> endobj 2�!�m%�+�^�hb�[�� w�q ��~�d(%K� ����!��>������$��@�˞x��S�I{F��\�� QJO���By $s�x�Tr%�3s���. Meningococcal Information & Waiver *Information about Global Waivers at HUHS. This information shall include the possible risks and benefits of the procedure or treatment. Please share your concerns, suggestions or compliments with us. Identify a caregiver who will be included in your discharge planning and sharing or post-discharge care information or instruction. The patient does not automatically receive a copy of his/her medical record upon discharge from the hospital. Include the name, dose, how often you take them, and the name of your pharmacy. Receive all the information that you need to give informed consent for any proposed procedure or treatment. We appreciate patients and their loved ones sharing their experiences and use this "voice of the patient" as an opportunity to improve our care. Yes. If you bring your medications to the hospital, send them home with your family once the nursing staff has seen them. Medical records must be completed by all physicians involved in the patient’s care prior to being copied and released to the patient. Additional forms will be brought to you for your signature after you’ve been assigned a room. Local law enforcement will be notified if the visitor refuses to comply. Unfortunately, medication errors happen. Receive all the information you need to give informed consent for an order not to resuscitate. You can print a release form for transfers of records to UHS or pick up a copy of the form from Health Records. We operate UHS Home Care PHC (call 607.763.5600) and UHS Home Care TTHH (607.763.8946). Wilson Place is located at 52 Harrison Street in Johnson City, across from Wilson Medical Center. While cell phones are permitted in all our hospitals, their use is limited as follows: In any UHS facility, please keep the ringer volume of the phone turned low. Note: The hospital can’t assume responsibility for valuables kept in your room or lost or broken dentures, eyeglasses, hearing aids, etc., unless the hospital is clearly responsible for the damage. 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. Click here to download the patient rights booklet. 0 This process can take up to 30 days. Staff at the center can help you find ways to live a healthier, happier life. Store medications in their original containers. Instead, students may complete Health Record Release – Medical Services form, authorizing UHS to disclose their health information to one or more of their parents. 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. Pharmacies have computers to check for interactions and allergies, but when your doctor gives you samples, this important check may be missed! Pathway’s telephone number is 888-891-6523. As a patient in a hospital in New York state, you have the right, consistent with law to: For the Parents' Bill of Rights, click here. Whether you need home care services, equipment or supplies, UHS can help. The UHS Medical Records staff can answer any questions you might have regarding access to family members' information. UHS can release your medical records to you or another person or entity. 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. To properly complete this form, fill out all sections. Unity 12 CIC. Make it known whether you clearly understand a contemplated course of action and what is expected of you. After your hospital stay is over, you have an opportunity to open the door to better health by discovering the resources of UHS' Stay Healthy Center at Oakdale Mall. If your doctor gives you samples, make sure that he/ she checks to be sure there are no interactions with your other medications. Participate in all decisions about your treatment and discharge from the hospital. There is no charge for use of the telephone or television in inpatient rooms. You’ll receive written discharge instructions prior to leaving the hospital. If after doing this you’re still not satisfied, please contact: Our goal is to provide all our patients with very good care, so your feedback is important to us since it helps us to continually improve our services. Admissions/registration is located: If you’re admitted through the Emergency Department you’ll be registered there. The hospital must provide you with the State Health Department telephone number. 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). Receive an itemized bill and explanation of all charges. 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. Some examples would be in response to a medical emergency, under a court order, and in response to workman’s compensation claims. Read the label every time you take a dose to make sure you have the right medication and that you are following the instructions. Sign up for eGuthrie; Family Access for eGuthrie; Health Information Exchange. Also list your medication and food allergies, and any over-the-counter medications, vitamins, nutritional supplements or herbal products that you take regularly. Please call the site you are requesting records from for further details on submitting the form. Transfer to UHS: Any time that your medications change, update your list too. Medical Record Release Form Allow 7–15 days for the retrieval, copying, and forwarding of your medical records. Do not let anyone give you medications without checking your name band. Once you have completed the form, it can be returned via e-mail, fax, mail, or hand delivery. State and federal laws determine who may have access to a patient’s information. Directions to Clayton State University 2000 Clayton State Boulevard Morrow, GA 30260 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. When you get ready to go home, have the doctor or nurse go over each medication with you and a family member. (607) 337-4295. UT does not recognize E-Signatures as valid signature for medical record releases. After discharge, the above charges will appear directly on your home telephone bill as “Hosp Tel Chg.” VISA, MasterCard and Discover are also accepted. Universal Authorization Form; Share Your Medical Record with any provider, anywhere. Student Vaccine Exemption. © 2021 United Health Services. 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. UHS will provide an interpreter for any patient or family who doesn’t speak English. Authorize those family members and other adults who will be given priority to visit consistent with your ability to receive visitors. If you wish to receive a paper copy of your records for your own use, you may be charged a fee for processing the request. We’ll make sure you obtain the necessary paperwork. Consent for Medical Treatment I voluntarily consent to be treated. {B�U�A�j��� �ɜ��,]1�i_�-��'��$缟�ﺎClrIqn}���>95$�63FNqU,���ioC"�m�Ht���d@#0�G��-+�X��Mǁ CMH Patient Financial Advocates also help patients make arrangements to secure interest free loans or to make other arrangements so they are able to receive essential health services. You have to ask your pharmacists, doctors, and nurses about your medications, and you have to expect answers. University Hospital Southampton. Mailing or faxing the completed form to the following address: CiOX Health 8501 Excelsior Dr. Madison, WI 53717 Fax: (608) 203-4580; Option 2 . Ask questions when you do not understand what you have been told about your care or what you are expected to do regarding care. * information about Global Waivers at HUHS information Management office: UHS release of information that you take a to... Your departure time they will be useful in giving credit to the staff at the of. 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