Get Northwestern Medicine Patient Rights And Responsibilities

Filling out the Northwestern Medicine Patient Rights And Responsibilities form online is essential for ensuring your rights as a patient are upheld. This guide provides clear, step-by-step instructions for successfully completing the form to express your needs and preferences.

Follow the steps to complete your form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal details in the designated fields. Start with your full name, followed by your address, including city, state, and zip code. This information helps identify you as a patient.
3. Enter your date of birth and social security number. This information is necessary for tracking your medical records accurately. Also, include your phone number for any follow-up communications.
4. Indicate the dates for which you are requesting a disclosure of records. The maximum time frame that can be requested is six years prior to your request date, so ensure these dates are accurate.
5. Specify the treatment location from where you want the accounting information. This will help streamline the processing of your request by directing it to the correct department.
6. Clarify any specific area or department from which you require an accounting of disclosures. This helps provide precise information tailored to your needs.
7. Review the fee section. Acknowledge whether you will incur any fees for your request. The first request in a 12-month period is free, while subsequent requests carry a $20 charge.
8. Direct your request to the Health Information Management manager at Northwestern Memorial Healthcare, using the provided address. This ensures that your request is processed correctly.
9. Acknowledge the response time indicated in the form. Typically, feedback is provided within 60 days, unless an extension is necessary. Be aware of your rights as a patient.
10. Finally, sign the form either as the patient or a legally authorized representative. Include the date and specify your relationship to the patient if applicable.
11. Once all sections are completed, save changes, download, print, or share the form as needed.

Complete your Northwestern Medicine Patient Rights And Responsibilities form online today to ensure your rights are protected.