Free Florida Authorization To Disclose Health Information Download

Health Information Management Dept.

P.O. Box 1289 Tampa, FL 33601-1289 Phone: (813) 844-7533

Authorization To Disclose Health Information

Street Address Apt

City State Zip Birth date Age

Home Phone Work Phone SSN

The undersigned hereby authorizes and requests Tampa General Hospital to provide to:

Identity of Third Party or Authorized Representative / Name of Health Care Facility

Street Address Suite/Floor

City State Zip Phone

Per Florida Statues, hospitals are authorized to charge a $1.00 per page for copies of medical records. Check the box next to each type of information to be disclosed (include dates where indicated):

• Most recent history and physical or specific date(s)

• Most recent discharge summary or specific date(s)

• Consultation reports, specify date(s)

• Laboratory results, specify types or dates

• Other diagnostic testing results, specify types or dates

• Entire record, specify date

• Abstract, specify date ( includes only pertinent treatment information)

• Other, specify

• Including HIV/AIDS testing, results, and/or treatment records

• Including Mental Health treatment records, excluding psychotherapy notes

• Including alcohol and/or drug abuse treatment records

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department or mail to the above address. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that any disclosure of information carries with it the potential for re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of health information, I can contact the Director of the Health Information Management Department at (813) 844-7525.

Unless otherwise revoked, this authorization will expire on the following date, event or condition:

If I fail to specify an expiration date, event or condition, this authorization will expire in 90 days.

Signature of Patient or Legal Representative Signature of Witness

If signed by Legal Representative, Relationship to Patient Date

Form #: A-503 Rev. 09/17/10 FAQ’s on the reverse side

Frequently Asked Questions:

How do I request my medical records?

You can request your records in person at our customer service window or mail in your request to the address listed on the reverse side.

Can I fax my request?

No. To ensure the expediency in which we receive and respond to requests from other medical facilities for immediate and emergent patient care, we are unable to accept requests by fax from anyone other than outside medical facilities.

Can I receive my records via fax?

No. Due to HIPAA rules and regulations, and to ensure every patient’s right to privacy, we only fax patient medical records to other medical facilities for immediate patient care.

Who can I call regarding my records? Billing/Radiology/etc. (ROI now has the ability to provide patients with a CD containing Radiology images (excluding mammograms).

ROI: (813) 844-7533 Radiology: (813) 844-7770 Billing: (813) 844-7291

What are the business hours for ROI?

Monday – Friday 8:00AM to 5:00PM Closed Weekends and Holidays

Is there a charge for copies of my medical records?

Yes. Per Florida Statute, we are authorized to charge $1.00 per page for copies of medical records. There is no charge for medical records if they are provided directly to your physician.

Once I request my medical records, how will I receive them?

We can mail them to you or you can arrange to pick them up. Please specify when requesting.

If I come to the customer service window, can I receive copies of my medical records while I wait?

If you are requesting records for one particular recent visit, then they can be provided while you wait. Multiple visits or copies of entire charts will take 7 to 10 business days to process. An invoice will be mailed and upon receipt of payment, records will be mailed to you.

How long does it take to receive my records once my request is received?

Once your request is received, it will take 7 to 10 business days to process and be mailed out to you.

When is my record available for release?

Medical records are available for release 5 to 7 days after discharge. This allows time for the Nursing Unit to complete their medical documentation and forward the record to the HIM department, and allows time for the HIM department to assemble and analyze the medical record for completeness.

Who can pick up my records?

Only you can pick up your records unless you write a letter authorizing someone else to pick up your records or specify this information on the signed and dated authorization form. The person you authorize to pick up your medical records will need to show identification before medical records are released.

Who can request my records?

Only you or the person/entity authorized by you to obtain records may request records. A Healthcare Surrogate or Power of Attorney appointed by you may request copies of your medical records. A copy of the corresponding documentation and appropriate identification must be presented before records will be released to a personal representative.

Can I request records on a deceased person?

Records on deceased patients can be requested by the Administrator of the deceased’s estate, next-of-kin (surviving spouse, adult children, parents, or adult siblings, respectively). Proper documentation and identification must be provided. This may include court documentation, death certificate, and documentation proving relationship; i.e. an adult child requesting their deceased parent’s records must provide proof that there is no surviving spouse and a birth certificate identifying patient as their parent.

How do I request someone else’s medical records?

Only under certain circumstances can you request and receive someone else’s medical records.

• You must be the parent of a minor child (under 18) who is not emancipated, or

• You must have Power of Attorney or Health Care Surrogate for the patient you are requesting, or

• You must provide a court order allowing you to obtain requested records.

What is an abstract?

An abstract is a summary of your visit that contains the pertinent information about your treatment. For a typical inpatient stay, an abstract could consist of a discharge summary or order, history and physical, consultations, operative reports, lab results, radiology reports, and any additional diagnostic testing results. An abstract does not contain any handwritten information unless it is one of the document types previously listed that is not available in the form of a typed document.

Form #: A-503 Rev. 09/17/10