Get Lexington Medical Center Medical Records Fax Number

MEDICAL RECORDS A Lexington Medical Center Physician Practice 146 North Hospital Drive Suite 550 West Columbia SC 29169 803 936-7410 FAX 803 936-7412 Patient Directed Agreement for Verbal Release of Protected Health Information Patient Name Date of Birth / / I agree and offer no objection to the verbal release of protected health information by the above named provider to the persons indicated below PERSON / ENTITY RELATIONSHIP TELEPHONE NUMBER 1 understand that this agreement will expire 18 months from the date of signature. I this agreement at any time by contacting the above named provider/practice either in writing or in person* 3 Revocation will not apply to information that has already been disclosed* Signature of Patient or Authorized Person Relationship Date Reason Patient is Unable to Sign If the patient is not present or is unable to agree or object to the use or disclosure of protected health information because of incapacity or an emergency circumstance the practitioner may use professional judgment to determine whether the disclosure is in the best interest of the individual and if so disclose only the protected health information that is directly relevant to the person s involvement with the individual s health care. The practitioner may also use professional judgment experience with common practice and the best interest of the patient in also allowing the listed individuals to act on behalf of the patient to pick up filled prescriptions medical supplies x-rays or other similar forms of protected health information* 8516-017-1 Rev* 7/2013. I this agreement at any time by contacting the above named provider/practice either in writing or in person* 3 Revocation will not apply to information that has already been disclosed* Signature of Patient or Authorized Person Relationship Date Reason Patient is Unable to Sign If the patient is not present or is unable to agree or object to the use or disclosure of protected health information because of incapacity or an emergency circumstance the practitioner may use professional judgment to determine whether the disclosure is in the best interest of the individual and if so disclose only the protected health information that is directly relevant to the person s involvement with the individual s health care. The practitioner may also use professional judgment experience with common practice and the best interest of the patient in also allowing the listed individuals to act on behalf of the patient to pick up filled prescriptions medical supplies x-rays or other similar forms of protected health information* 8516-017-1 Rev* 7/2013.