Cincinnati Children's Authorization for Disclosure of PHI
This document is used to authorize Cincinnati Children's Hospital Medical Center to use and disclose protected health information. It includes sections for patient information, release details, and purpose of the disclosure. The form must be completed, signed, and submitted to the HIM department.
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How do I fill this out?
To fill this form, provide the necessary patient and guardian information. Ensure each section is completed and signed. Submit the form through mail, fax, or email.
How to fill out the Cincinnati Children's Authorization for Disclosure of PHI?
1
Enter patient and legal guardian information.
2
Select the method and purpose of the disclosure.
3
Specify the dates and types of medical records needed.
4
Sign the form where indicated.
5
Submit the form via mail, fax, or email.
Who needs the Cincinnati Children's Authorization for Disclosure of PHI?
1
Patients seeking to disclose their medical records for continued care.
2
Attorneys needing medical records for legal purposes.
3
Parents or legal guardians requesting information for their children.
4
Insurance companies requiring medical records for claim processing.
5
Educational institutions needing health records for student admissions.
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What are the instructions for submitting this form?
Submit the completed form via US Mail to Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5015, Cincinnati, Ohio 45229-3039. Fax the form to (513) 636-6729. Email the form to ROI@cchmc.org. Ensure all sections are completed and signed before submission. It is advisable to keep a copy of the form for your records.
What are the important dates for this form in 2024 and 2025?
The form must be submitted within one year of the signature date. Records will be released upon verbal or written request for up to one year from the date of signature. Expiry and other critical dates should be noted in the form as specified.
What is the purpose of this form?
The Authorization for Use and/or Disclosure of Protected Health Information form is designed to allow Cincinnati Children's Hospital Medical Center to use and disclose a patient’s medical information. This authorization ensures patients and their legal guardians can manage their medical records effectively for various purposes such as continued care, legal processes, or insurance claims. By completing this form, authorized individuals can control the release of sensitive health information to specified entities and for designated purposes. The form helps safeguard patient privacy while facilitating necessary information sharing.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for patient name, date of birth, and gender.
- 2. Contact Details: Fields for the address, phone number, and email of the patient or guardian.
- 3. Release To: Fields to specify the recipient’s information and method of delivery.
- 4. Purpose: Options to select the purpose of the information release, such as medical care or legal reasons.
- 5. Dates of Treatment: Fields to specify the dates of treatment being requested.
- 6. Information to Release: Options to specify the type of medical records being requested.
- 7. Expiration: Field to set the expiry date of the authorization.
- 8. Signature: Fields for the patient’s signature and date, and if applicable, the guardian's signature and date.
- 9. Submission: Instructions for submitting the completed form via mail, fax, or email.
What happens if I fail to submit this form?
Failing to submit the form could delay or prevent the release of necessary medical records. Delays can affect patient care, legal proceedings, or insurance claims.
- Patient Care: Delayed submission may result in not having important medical records for continued treatment.
- Legal Proceedings: Inability to present medical records for court cases may hinder legal processes.
- Insurance Claims: Lack of submitted records can delay or deny insurance claims processing.
How do I know when to use this form?
- 1. Medical Care: When continuing patient treatment with another healthcare provider.
- 2. Legal: For use in legal cases involving medical records.
- 3. Insurance: When submitting claims to insurance companies.
- 4. Education: For school or university admissions requiring health records.
- 5. Military: For military recruitment or service-related health records requests.
Frequently Asked Questions
How do I fill out the PHI Authorization Form?
Provide patient and guardian details, choose the purpose and format for disclosure, sign the form, and submit it accordingly.
Where can I submit the completed form?
Submit the form via mail, fax, or email to the HIM department as instructed in the form.
Can I edit this form online?
Yes, you can edit this form using PrintFriendly’s online PDF editor.
Is it mandatory to sign the form electronically?
Yes, the form requires an electronic signature to be considered valid.
How long does it take to process the request?
The processing time can take up to 60 days, as per HIPAA guidelines.
Are there any fees for requesting medical records?
Fees may apply if records are sent to a third party, as mentioned in the form.
Can I save my edited form on PrintFriendly?
Yes, you can save and download your edited form on PrintFriendly.
What should I do if I need help filling out the form?
Contact the HIM department at (513) 636-8233 for assistance.
Can I request records for multiple dates?
Yes, you can specify the dates of treatment needed in the form.
How will I receive my requested records?
Records can be sent via US Mail, MyChart, picked up, or emailed as per your choice.
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