This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Authorization Release Form For Medical Records In Maricopa
State:
Multi-State
County:
Maricopa
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
FAQ
Release of Information Authorization Under the HIPAA Privacy Rule, when a release of information is intended for purposes other than medical treatment, healthcare operations, or payment, you'll need to sign an authorization for ROI.
How to Transfer Your Records to VA View and download your health records on the Secure Patient Portal. This only applies to health records classified as sensitive. Fill out and submit a Form SF 180, Request Pertaining to Military Records. Submit a request in-person at your nearest military hospital or clinic.
Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.
Generally, Arizona law requires health care providers to keep the medical records of adult patients for at least 6 years after the last date the patient received medical care from that provider.
When should I use VA Form 21-4138? You should use the form when you need to provide extra information, context, or statements to support your claim for VA benefits. It's commonly used to clarify details, offer explanations, or submit additional evidence.
Use VA Form 10-5345 to authorize us to share your health information with a non-VA (or third-party) individual or organization.
How to submit a medical records request. You'll need to fill out an Individuals' Request for a Copy of Their Own Health Information (VA Form 10-5345a). Submit your completed form to your VA health facility's medical records office. This office is also called a Release of Information Office.
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.
The Personal Health Information Protection Act (PHIPA) gives a patient (or their substitute decision-maker) the right to see or receive a copy of their personal health information (PHI). Before you request access to personal health information, please browse the information provided below.