Fillable Stat/Continuity of Care Requests Only, Fax to 1-855-446-6008

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Stat/Continuity of Care Requests Only, Fax to 1-855-446-6008

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Tampa HCA Shared Service Center – HSC Release of Information
6451 126
th
Avenue North, Largo, FL 33773
Phone (866) 463-7272 Email: HSCT.MRRequest@Parallon.com
Stat/Continuity of Care Requests Only, Fax to 1-855-446-6008
Section A: This section must be completed for all Authorizations
Patient Name: Date of Birth: Patient’s Phone: Last 4 digit SSN:
(optional)
Recipient’s Name:
Address 1: Address 2: Recipient’s Phone:
City: State: Zip:
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 Provider Fax Number
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.
Email Address (If email checked above. Please print legibly):
This authorization will expire on the following: (Fill in the Date or the Event but not both.)
Date: Event:
Purpose of disclosure:
Hospital to release records from:
Aventura Hospital and Medical Center
Kendall Regional Medical Center
Mercy Hospital
Northwest Medical Center
Plantation General Hospital
University Hospital and Medical Center
Westside Regional Medical Center
Description of information to be used or disclosed
Is 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.
Description: Date(s): Description: Date(s): Description: Date(s):
Abstract (most common)
Entire medical record
Admission form
Dictation reports
Physician orders
Intake/outtake
Clinical test/radiology result
Medication sheets
Operative information
Cath lab
Special test/therapy
Rhythm strips
Nursing information
Transfer forms
ER information
Labor/delivery summary
OB nursing assess
Postpartum flow sheet
Itemized bill:
UB-04:
Other:
Other:
I acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, genetic information,
psychiatric, HIV testing, HIV results or AIDS information. (Initial)
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 redisclosed.
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 can get a copy of this form after I sign it.
Section B: Is the request of PHI for the purpose of marketing and/or does it involve the sale of PHI? Yes No
If yes, the health plan or health care provider must complete Section B, otherwise skip to Section C.
Will the recipient receive financial payment in exchange for using or disclosing this information? Yes No
If yes, describe:
May the recipient of the PHI further exchange the information for financial payment? Yes No
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’s Representative: Relationship to Patient:
ID verified by: ___________ (Initials)
AUTHORIZATION FOR RELEASE OF PHI
Patient Label
*ROI*
*ROI* HCA-840-00434 Rev. 03/19 Page 1 of 1
Directions for Completing the Authorization to Release Information
**Note: Release of information will occur after hospital discharge
Section A:
1. Provide the patient’s name, date of birth, phone number, and last 4 digits of SSN (this is
optional).
2. Provide the name of the recipient (receiver) of the information. The recipient is whoever is going
to receive the records. The recipient of the information may be someone other than the patient. It
may be the patient’s spouse, parent, power of attorney, another healthcare provider, etc. If the
recipient’s name is the same as the patient, just write “SELF”
3. If the recipient is the patient, provide the address of the patient. If the recipient is different than
the patient, provide the address and phone number of the recipient.
4. Next check the method of delivery: paper copy, electronic copy (CD, DVD, etc.) or email. If you
want the information faxed to your provider, indicate the fax number. If by email, select whether
you want the email encrypted or not encrypted. Provide the email address, if you selected email.
When requesting medical records to be sent unencrypted via email, your health information is
not protected from unauthorized access.
5. Indicate when this form expires. Put a date or an event (event example: the end of my outpatient
therapy), but not both.
6. Provide the reason for disclosure, examples are: further treatment, insurance purposes, for
attorney, personal use, etc.
7. Indicate from which hospital you need records.
8. Were you seen by a psychiatrist/psychologist while at the hospital and do you want notes by
them? If YES, select YES and you have to fill out two authorization forms, one for the behavioral
health reports and one for the other types of reports. If NO, select NO and continue.
9. At DESCRIPTION indicate what information you are requesting. Most common is the abstract,
which contains the discharge summary, history and physical, ER report, consults and operative
reports from the physicians, along with test results such as labs, radiology, and pathology.
Otherwise, indicate the specific information you need. Please indicate the dates of service.
10. Initial that you acknowledge and consent that the information requested may contain the special
types of information listed.
11. There may be a copy fee for the information you requested. Most requests will be sent to our
copy service at Tampa Shared Service Center. Their contact information is on the top of the
other side of this form.
Section B:
1. Are you using the information you requested for marketing purposes or selling the information, if
not, answer NO and skip the next two questions and go to Section C. If YES, answer YES and
continue with the next two questions.
2. If you are going to receive money in exchange for this information, answer YES. Otherwise
answer NO.
3. If you give permission to the recipient (receiver) to exchange the information for money, answer
YES. Otherwise answer NO.
Section C:
1. The patient must sign and date the form. OR
2. The patient’s LEGAL representative, example: power of attorney, legal guardian, healthcare
surrogate, must sign and date the form. (A spouse is not a LEGAL representative unless they
have LEGAL power of attorney or healthcare surrogacy paperwork.)
3. A copy of the LEGAL paperwork must be with this request.
Please send a copy of the patient’s ID or the legal paperwork mentioned above, along with this request, to
Tampa Shared Service Center. Their contact information is on the other side of this form.
HCA-840-00434 Rev. 03/19
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StatContinuity of Care Requests Only, Fax to 1-855-446-6008

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Completed 20 May 2021

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