S form is NOT required for photos or videos of patients used for the purposes of treatment or diagnosis, where the photo and/or video becomes part of the patient s medical record and is not used for any other purpose. Photography/Videography Release: I authorize the University of North Carolina Health Care System ( UNC HCS ) to take photographs and/or videos, or to allow third parties to take photographs and/or videos, of for the following uses: patient nam.
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How to fill out the UNC Medical Center MIM 739 Form online
The UNC Medical Center MIM 739 form is an essential document for patient photograph and video information release authorization. Filling out this form accurately is important to ensure that the consent for use of images and related information is properly documented.
Follow the steps to complete the form online:
- Press the ‘Get Form’ button to acquire the form and open it in your preferred online editing tool.
- Begin by filling out the patient’s name in the designated field, ensuring that it is spelled correctly.
- Indicate which uses you authorize by checking the appropriate boxes for public relations, medical purposes, or educational purposes. You may select multiple options.
- If applicable, provide specific applications under the 'Other' section to specify any additional intended uses of the photographs or videos.
- Read the information release section carefully. Decide whether to consent to the use of your name and indicate your choice by selecting the appropriate option.
- In the next section, provide any additional information you authorize to be shared about yourself, your medical condition, or your treatment.
- Complete the expiration section indicating an expiration date or condition for this authorization to remain valid.
- Sign the form by providing your signature, printed name, and the date and time it is completed. If you are signing on behalf of the patient, ensure to document your authority.
- If needed, a witness should also sign and date the form in the area provided.
- Once all fields are completed, make sure to save your changes. You can then download, print, or share the completed form as needed.
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What is the nurse line for UNC hospital?
Call 919-966-2281. During regular hours of operation, schedule an appointment or connect with a registered nurse to ask questions. After hours, the line connects with Health Link, a nurse advice system associated with UNC Health Care.
How do I file a complaint with UNC Hospital?
I need to share a complaint. In person. By phone at 984-974-5006. By mail to the Patient Relations Department, UNC Medical Center, 101 Manning Drive, Chapel Hill, NC, 27514. By email at patient.relations@unchealth.unc.edu.
How do I get my NC hospital records?
For information about your medical record, please see this Medical Records page or call (984) 974-3226. If you would like to request a copy of information in a medical record, please FAX a completed authorization form to (984) 974-0474.
Which of the following is the patient responsibility?
Patient Responsibilities Patients are responsible for providing correct and complete information about their health and past medical history. Patients are responsible for reporting changes in their general health condition, symptoms, or allergies to the responsible caregiver.
How do I access my UNC Health email?
Access your UNCHealth email from any location, any time, by using https://mail.unch.unc.edu Opens in new tab and dual authentication.
What is the medical record number?
A medical record number (MRN) is a unique identifier assigned to a patient in an electronic health record (EHR), practice management, or healthcare IT system. The MRN is used to keep track of medical history, diagnoses, treatments, and other important information related to patient care.
How do I request records from UNC?
Sign in to My UNC Chart or the patient portal where you got care and request a copy of your medical records. Fill out an authorization form for medical records and drop it off at one of our locations in person. Fill out an authorization form for medical records and mail it to one of our locations.
How do I contact UNC Health?
Please contact us using any of the mechanisms below: Appointments: Call 919-966-2281, visit campushealthappointments.unc.edu or use the web portal at healthyheels.unc.edu. Symptoms, problems, or concerns: Call us at 919-966-2281. Feedback about Campus Health: Use our online Suggestion Box - we value your feedback!
What are the patient rights in NC?
(1) A patient has the right to respect, dignity, and comfort. (2) A patient has the right, upon request, to be given the name of his or her attending physician, the names of all other physicians participating in his or her care, and the names and functions of other health care persons having contact with the patient.
What is the phone number for UNC Transfer Center?
UNC Transfer Center Contact the Transfer Center toll-free at 1-800-806-1968.
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