UDI HIPAA AND RECORD RELEASE

UDI HIPAA AND RECORD RELEASE
HIPAA COMPLIANCE
Name

First NameLast Name (Include Maiden if Applicable)
Date of Birth

MonthDayYear
Date
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information toonlyyou, your doctor, your insurance and the person(s) listed below. You have the right to revoke this consent,in writing, signed by you. However, such a revocation will not be retroactive. I authorize the release of my protected health information, including records, results and images to the following person(s): (Please check all that apply and indicate names of party authorized) Spouse Name Children

SpouseChildrenOther
Spouse Name
Children Name (if authorized)
Other
MESSAGES OR APPOINTMENT REMINDERS

Messages will be of a non-sensitive nature, such as appointment reminders.
I authorize UDI to leave messages at provided home / cell using practice name.

YESNO
I authorize UDI to text or email my provided contact.

YESNODO NOT leave a message or text me.
OUTSIDE IMAGES/RECORDS RELEASE
UDI is committed to providing you and your physician quality care. If you have had relevant imaging done, please complete this portion of the form. Our Radiologists aim provide a comprehensive analysis for your condition. Please list ALL related prior Imaging Facilities. ONLY complete the below "Prior Images/Records" portion below if applicable.

I DO NOT authorize UDI to request any outside records on my behalf.
Name of the *Outside Facility or Hospital * where your prior scans were performed
Type of Films
Date of Service

MonthDayYear
Date
UNIVERSITY DIAGNOSTIC INSTITUTE 111 N. LAKEMONT AVE.

Push Images via PS. Please still Fax Reports

UNIVERSITY DIAGNOSTIC INSTITUTE

I have read and understand the terms of the HIPAA and Record Release sections above.
PATIENT/PARENT/LEGAL REPRESENTATIVES SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty:

UDI HIPAA AND RECORD RELEASE

HIPAA COMPLIANCE

OUTSIDE IMAGES/RECORDS RELEASE