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- IL Edward-Elmhurst Health Authorization To Use And Disclose Health Information 2021
Get IL Edward-Elmhurst Health Authorization To Use And Disclose Health Information 2021-2024
Urst Health AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION Consent Rescinded: Date/Time: Witness: 1. Patient information Patient s Legal Name: Date of Birth: Street Address: City, State, Zip Code: Telephone Number: Approximate dates of treatment* (*Must be completed) 2. I authorize the use and disclosure of the individually identifiable health information ( PHI ) about me that is indicated in the checklist below. I understand that such uses and disclosures may only be made by.
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Eeg FAQ
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Edward Hospital & Health Services (Edward Hospital Services Corporation) is a healthcare provider located in southwest suburban Naperville, DuPage County, Illinois.
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Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.
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You can also send them to Edward HIM/Medical Records Department, 801 S. Washington Street, Naperville, IL 60540, fax to 331-221-2390 or email to mychart.activation@eehealth.org.
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