Patient Medical Records Release

NASH Patient Medical Records Release Form
- Provider Name (the physician who wrote the prescription for the medication(s) you are getting from NASH)
- Office Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name of Second Provider - Specialist (if applicable)
- Office Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- This information will be released to:
  
  Network of Advanced Specialty Healthcare (NASH)
  
  2637 S 158th Plaza, Suite 230, Omaha, NE 68130
  
  Phone: (833) 833-6204 | Fax: (303) 593-6548
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Email
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Contact Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Covering Period from Date
  
  MonthDayYear
  Date
- Expiration Date (This authorization will expire one year (12 months) from the date signed unless otherwise specified)
  
  MonthDayYear
  Date
- Please check the type of information to be released (check all that apply)
  
  History and physical as it pertains to the medications to be provided by NASHPhotographsLab test resultsDiagnosis and treatment codesProgress notesDischarge summary
- Purpose of Request (must check one).
  
  Treatment or consultationBilling or claims paymentAt the request of the patientOther
- I understand if my medical record contains information in reference to drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and/or other sensitive information, I agree to its release.
  
  YesNo
- I understand if my medical record contains information in reference to HIV/AIDS (Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome) testing and/or treatment, I agree to its release.
  
  YesNo
- Time Limit & Right to Revoke Authorization
  
  Except to the extent that action has already been taken in reliance on this
  authorization, at any time I can revoke this authorization by submitting a notice in
  writing to the Privacy Site Coordinator or to the Privacy Officer. This authorization will
  automatically expire upon notification of my death.
  
  Re-disclosure
  I understand the information disclosed by this authorization and any re-disclosure by NASH is subject to HIPAA. I hereby authorize NASH to disclose my personal information, including elements of my medical record, to its employees, officers, and contracted physicians, as well as to respond to requests from government authorities (e.g. border patrol) and to use my personal information to the extent necessary to connect me with my medication.
  
  Signature of Patient or Personal Representative Who May Request Disclosure
  I understand that I do not have to sign this authorization, but that decision may impact my ability to access NASH’s services. I can inspect or copy the protected health information to be requested, used, or disclosed. I authorize NASH to request, use, and disclose the protected health information specified above.
- *I authorize NASH to discuss my health information and care plan with this/these family member(s):
- Patient or Guardian / Legal Representative
  
  First NameLast Name
- Today's Date
  
  MonthDayYear
  Date
- Signature of Patient or Guardian / Legal Representative
- Should be Empty:

NASH Patient Medical Records Release Form