WA Providence St. Josephs Hospital Authorization Form 2006-2025 free printable template

AUTHORIZATION FORM I, Phone #, hereby authorize St. Joseph s Hospital to (Requestor Name)release information contained in the medical record of: Patient Name: (please print) Date of Birth Soc Sec

How to fill out WA Providence St Josephs Hospital Authorization

How to fill out WA Providence St. Josephs Hospital Authorization Form

1. Obtain the WA Providence St. Joseph's Hospital Authorization Form from the hospital's website or in-person.
2. Fill out the patient's personal information at the top of the form, including name, date of birth, and contact information.
3. Specify the information you authorize to be released, such as medical records or billing information.
4. Indicate the purpose of the release, for example, medical treatment or legal purposes.
5. List the person or organization to whom the information will be sent.
6. Sign and date the form, ensuring the signature matches the name of the patient.
7. If the patient is a minor, a parent or guardian must sign the form.
8. Submit the completed form to the designated department at Providence St. Joseph's Hospital.

Who needs WA Providence St. Josephs Hospital Authorization Form?

1. Patients seeking to share their medical information with another healthcare provider.
2. Individuals involved in legal proceedings requiring access to medical records.
3. Family members or guardians handling medical decisions for minors or incapacitated patients.

People Also Ask about

How to get medical records from Providence Hospital Washington DC?

You may also fax your request to 202-854-7931. If you have questions regarding release of medical records or need to check on the status of a request, please call 202-854-7000. If you choose not to transfer your records, they will be maintained in ance with Providence's medical record procedures.

How long do medical records need to be kept in Washington state?

Unless specified otherwise by the department, a hospital shall retain and preserve all medical records which relate directly to the care and treatment of a patient for a period of no less than ten years following the most recent discharge of the patient; except the records of minors, which shall be retained and

What are the medical records laws in Washington state?

Washington medical records laws state that only the patient may authorize disclosure of medical records to anyone other than health care providers, penal institution officials, or public health authorities.

How much does it cost to get medical records in Washington state?

Your provider can charge a "reasonable fee" for your copies. You may have to pay up front. In 2022, a health care provider can charge up to $1.24 a page for the first thirty pages, 94 cents a page after that, and a $28 clerical fee. WAC 246-08-0400.

What is the Hipaa law in Washington state?

The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically.

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What is WA Providence St. Josephs Hospital Authorization Form?

The WA Providence St. Josephs Hospital Authorization Form is a legal document that grants permission for the hospital to use or disclose a patient's medical information, as required by healthcare providers for treatment, payment, or healthcare operations.

Who is required to file WA Providence St. Josephs Hospital Authorization Form?

Patients or their legal representatives are required to file the WA Providence St. Josephs Hospital Authorization Form when they want their medical information shared with a third party or when seeking specific medical treatment.

How to fill out WA Providence St. Josephs Hospital Authorization Form?

To fill out the WA Providence St. Josephs Hospital Authorization Form, individuals must provide their personal details, specify the information to be released, identify the recipient of the information, and sign and date the form, acknowledging their consent.

What is the purpose of WA Providence St. Josephs Hospital Authorization Form?

The purpose of the WA Providence St. Josephs Hospital Authorization Form is to ensure that patient privacy is respected while allowing necessary medical information to be shared legally and appropriately for treatment and care.

What information must be reported on WA Providence St. Josephs Hospital Authorization Form?

The information required on the WA Providence St. Josephs Hospital Authorization Form typically includes the patient's name and contact information, a description of the medical records to be disclosed, the purpose of the disclosure, and the signature of the patient or their representative.