Lawrence General Hospital Authorization to Use or Disclose Protected Health Information 2011 free printable template

GH Medical Record # Health Information Services Department 1 General St. Lawrence, MA 01842-0389 Phone: 978-683-4000 Ext. 2046 Fax: 978-557-9948 Email: info lawrencegeneral.org Authorization to Use

How to fill out Lawrence General Hospital Authorization to Use or

How to fill out Lawrence General Hospital Authorization to Use or Disclose

1. Obtain the Lawrence General Hospital Authorization to Use or Disclose form from the hospital website or front desk.
2. Fill in your full name, address, and contact information at the top of the form.
3. Specify the information you wish to be released, such as medical records, billing information, etc.
4. Indicate the purpose for the disclosure, such as for personal use, legal reasons, or insurance.
5. List the name(s) of the individual(s) or organization(s) to whom the information will be disclosed.
6. Sign and date the form to authorize the release of your information.
7. Submit the completed form to Lawrence General Hospital either in person, by mail, or by fax.

Who needs Lawrence General Hospital Authorization to Use or Disclose?

1. Patients seeking to share their medical information with other healthcare providers.
2. Individuals involved in legal matters that require access to medical records.
3. Organizations or third parties that need proof of health status for insurance purposes.
4. Research institutions that require patient information for study purposes with patient consent.

People Also Ask about

How much does it cost to get medical records in MA?

Permissible Rates for Copying Records Massachusetts law allows physicians not covered by HIPAA to charge a base fee of $15.00 for each request, as well as a copying charge of $0.50 per page for the first 100 pages, and $0.25 per page in excess of 100. (The cost may be adjusted ing to the Consumer Price Index.)

What is the fax number for Wentworth Douglass Hospital medical records?

Fax: 844−918−0781 Please print all information clearly in order to process your request in a timely manner.

What is the fax number for Massachusetts General Brigham medical records?

For Release of Information questions, please call Customer Service at 617-726-2361. For Audit-related questions, please call 857-282-8730 or fax 617-726-3025.

What is the fax number for mass eye and ear medical records?

Patients can use Mass General Brigham Patient Gateway to access their medical records and request additional records or by faxing an authorization form to the Mass General Brigham Release of Information team at 617-726-3661 or mailing the form to 121 Innerbelt Road, Somerville, MA 02143-4453.

How do I get my medical records in Oregon?

Patients can obtain this information by calling the Board at 971-673-2700. For additional information on medical records, refer to OAR 847-012-0000.

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What is Lawrence General Hospital Authorization to Use or Disclose?

It is a legal document that allows Lawrence General Hospital to share a patient's medical information with designated individuals or entities.

Who is required to file Lawrence General Hospital Authorization to Use or Disclose?

Patients or their legal representatives must file the authorization to allow the hospital to disclose their medical information.

How to fill out Lawrence General Hospital Authorization to Use or Disclose?

The authorization form must be filled out completely, including patient information, the specific information to be disclosed, the purpose for the disclosure, and the signatures of the patient or representative.

What is the purpose of Lawrence General Hospital Authorization to Use or Disclose?

The purpose is to ensure that patient health information is shared in accordance with privacy regulations and that patients have control over their own medical information.

What information must be reported on Lawrence General Hospital Authorization to Use or Disclose?

The form must include the patient's name, date of birth, the specific information being disclosed, the organizations or individuals receiving the information, and the patient's signature along with the date.