Medical Information Release Consent Form In Bronx

State:
Multi-State
County:
Bronx
Control #:
US-00459
Format:
Word; 
Rich Text
Instant download

Description

This Consent to Release of Financial Information authorizes all banks, financial institutions, businesses, employers, credit reporting agencies and any other businesses to which this person is indebted or have assets located, to provide information concerning his/her finances and assets, without liability, to the person or entity named in this Consent form. This form is applicable in any state.

Form popularity

FAQ

To request a copy of a medical record from a hospital, call or write to the hospital holding the record. You must speak to the Medical Records Department and request a release of medical information authorization form from the hospital.

Once your request is received, a physician or health care facility has 10 days to provide you with an opportunity to inspect your records. The law does not provide a specific time period by which copies of medical records must be provided.

Call the NY State of Health Customer Service Center at 1-855-355-5777.

Personal health record (PHR) Electronic medical record (EMR)

The NYS Department of Health, however, requires medical doctors to retain records for any adult patients for 6 years. Minor patients are kept for 6 years and until one year after the minor reaches the age of 18 (whichever is longer). For hospitals, medical records must be kept for six years from the date of discharge.

Yes. For NYC Health + Hospitals Hospital records, you may call 866-390-7404.

I hereby authorize use or disclosure of protected health information about me as described below. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

If you have any questions regarding the release of your health records (clinical and/or counseling), please contact the HIMS Correspondence Unit at (212) 443-1272 or health.hims@nyu. .nyu/shc/medicalrecords.

Yes. For NYC Health + Hospitals Hospital records, you may call 866-390-7404.

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Medical Information Release Consent Form In Bronx