MA Fenway Health Authorization for Disclosure of Protected Health Information 2010 free printable template

ANSI BUILDING 1340 Boston Street Boston MA 02215 TEL 617.267.0900 WE B fenwayhealth.org AUTHORIZATION FOR DISCLOSURE OF Protected Health Information PATIENT NAME ADDRESS PHONE NUMBER SOCIAL SECURITY

How to fill out fenway health medical records

How to fill out MA Fenway Health Authorization for Disclosure of Protected Health

1. Obtain the MA Fenway Health Authorization for Disclosure of Protected Health form from the Fenway Health website or at their office.
2. Fill in your personal details, including your full name, date of birth, and contact information.
3. List the specific information you want to disclose, such as medical records, treatment history, or any other relevant details.
4. Specify the recipient(s) of the disclosed information, including their names and contact details.
5. Indicate the purpose of the disclosure, such as coordination of care, insurance claims, or other relevant reasons.
6. Sign and date the authorization form to confirm your consent.
7. If required, have a witness sign the authorization form.
8. Submit the completed form to Fenway Health or the designated recipient.

Who needs MA Fenway Health Authorization for Disclosure of Protected Health?

1. Patients seeking to share their medical information with another healthcare provider.
2. Individuals applying for health insurance or benefits that require medical records.
3. Case workers or legal representatives needing access to a patient's health information for support services.
4. Family members or caretakers who need information about a patient's health to provide appropriate care.

People Also Ask about

How do you request medical records from a hospital letter?

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.]

Does Fenway Health use Epic?

The reason for this is Fenway was part of a group of 12 area community health centers known as the Community Technology Collaborative that switched to Epic. Please see the below videos on how to link your accounts.

How do I make medical records?

Use a filing cabinet, 3-ring binder, or desktop divider with individual folders. Store files on a computer, where you can scan and save documents or type up notes from an appointment. Store records online using an e-health tool; certain online records tools may be accessed, with permission, by doctors or family members.

What is the phone number for Fenway Health refill?

You can also dial one of the prescription refill direct lines: 617.927. 6333 for prescriptions from a medical or behavioral health provider at 1340 Boylston Street.

What hospital is Fenway Health affiliated with?

How We Offer a High-Quality Experience for all Patients. Fenway Health is affiliated with Beth Israel Lahey Health. All physicians hold faculty appointments at Harvard Medical School. Research affiliations include Massachusetts General Hospital, Brigham and Women's Hospital, and Brown University Medical School.

How do I contact Fenway Health?

If you have any questions about Fenway Health and would like to speak to a Fenway employee, please call us at 617.267. 0900 during business hours. You can also check out our FAQ page to find out how to get copies of your medical records, what insurance plans we accept, and answers to other questions.

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What is MA Fenway Health Authorization for Disclosure of Protected Health?

MA Fenway Health Authorization for Disclosure of Protected Health is a legal document that allows healthcare providers to disclose a patient's protected health information (PHI) to third parties designated by the patient.

Who is required to file MA Fenway Health Authorization for Disclosure of Protected Health?

Patients receiving care at Fenway Health are required to file this authorization if they wish to allow the sharing of their protected health information with other individuals or entities.

How to fill out MA Fenway Health Authorization for Disclosure of Protected Health?

To fill out the MA Fenway Health Authorization for Disclosure of Protected Health, patients should complete the form by providing their personal information, specifying the information to be disclosed, identifying the recipients of the information, and signing and dating the form.

What is the purpose of MA Fenway Health Authorization for Disclosure of Protected Health?

The purpose of this authorization is to protect patient privacy while allowing the necessary sharing of health information for treatment, payment, or healthcare operations as requested by the patient.

What information must be reported on MA Fenway Health Authorization for Disclosure of Protected Health?

The information that must be reported includes the patient's name, date of birth, the specific health information to be disclosed, the individuals or organizations receiving the information, the purpose of the disclosure, and the patient's signature along with the date.