Fillable Nashville Health Information Management Service Center (HSC) Release

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Nashville Health Information Management Service Center (HSC) Release

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Nashville Health Information Management Service Center (HSC)
Release of Information
PO Box 290429, Nashville Tennessee 37229
Phone: 615.695.8700, Toll Free: 1-866-270-2311, Fax 1-855-6104
Section A: This section must be completed for all Authorizations
Patient Name: Birth Date: Last 4 digits SSN
(optional):
Facility Name: Recipient’s Name:
R
ecipient’s Phone:
Facility Address:
Ad
dress:
Patient Email: City: State Zip:
This authorization will expire ninety days from the date of signature unless otherwise indicated
below.
Date: Event:
Purpose of disclosure:
Request Delivery (If left blank, a paper copy will be provided): Paper Copy Electronic
Media, if available (e.g.,USB drive, CD/DVD)
Encrypted Email Unencrypted Email
_________________________________________________________________________
NOTE: In the event the facility is unable to accommodate an electronic delivery as
requested, an alternative delivery method will be provided (e.g., paper copy). There is
some level of risk that a third party could see your PHI without your consent when
receiving unencrypted electronic media or email. We are not responsible for
unauthorized access to the PHI contained in this format or any risks (e.g., virus)
potentially introduced to your computer/device when receiving PHI in electronic
format or email.
I
s this request for psychotherapy notes?
Yes, then this is the only item you may
request on this authorization. You must submit another authorization for other items
below.
No, then you may check as many items below as you need.
Nashville Health Information Management Service Center (HSC)
Release of Information
552 Metroplex Drive, Nashville Tennessee 37211
Phone: 615.695.8700, Toll Free: 1-866-270-2311, Fax 1-877-865-9738
Description:
check all that apply
Date(s) Description:
Description: check
all that apply
Date(s) Description: check
all that apply
Date(s)
All PHI in medical
record
Admission form
Dictation reports
Physician orders
Intake/outtake
Clinical Test
Medication Sheets
Operative
Information
Cath lab
Special
test/therapy
Rhythm Strips
Nursing
Information
Transfer forms
ER Information
Labor/delivery
sum.
OB nursing
assess
Postpartum
flow sheet
Itemized bill:
UB-92:
Other:
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol,
drug abuse, psychiatric, HIV testing, HIV results or AIDS information. __________ (Initial)
If not applicable, check here.
I understand that:
1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on
signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect
on any actions taken prior to receiving the revocation. Further details may be found in the
Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released
information may no longer be protected by federal privacy regulations and may be re-
disclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a
reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Section B: Is the request of PHI for the purpose of marketing? If yes, the health plan or
health care provider must complete Section B, otherwise skip to Section C.
Will the recipient receive financial or in-kind compensation in exchange for
using or disclosing this information?
Yes No
If yes, describe:
Nashville Health Information Management Service Center (HSC)
Release of Information
552 Metroplex Drive, Nashville Tennessee 37211
Phone: 615.695.8700, Toll Free: 1-866-270-2311, Fax 1-877-865-9738
Section C: Signatures
I have read the above and authorize the disclosure of the protected health information as stated.
Signature of Patient/Patient’s Representative:
Date:
Print Name of Patient/Representative:
Relationship to
Patient:
*roi*
(rev 8/24/15)
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Nashville Health Information Management Service Center (HSC) Release

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Completed 3 December 2020

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