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 Suffolk
State:
Multi-State
County:
Suffolk
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
Description
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FAQ
Here is a suggested letter you can employ. I would like to make an application to see my medical records under the Data Protection Act 1998 (living patients). I wish to inspect the records made during the period (approximate date) to (approximate date).
New York State Law gives patients and other qualified individuals access to medical records. There are some restrictions on what may be obtained and fees may be charged by physicians, other health care professionals and facilities for providing copies.
You have a legal right to access the personal information held about you by health and care organisations. You can already obtain this information at any time you choose by making a Subject Access Request (SAR), however, it takes up to one calendar month for your GP practice to provide the information.
To obtain a copy of your hospital records you will need to apply in writing to the hospital's records manager at the hospital where you received your treatment. Links to the various NHS hospital trusts: NHS England: NHS Choices website.
If you or the person whose records you are requesting on behalf of are unregistered, PCSE will process the access application within 28 days. In certain circumstances, this may not be possible (for example, where the record cannot be traced, or is held by a third party storage provider outside of the control of PCSE.)
Personal health record (PHR) Electronic medical record (EMR)
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.
New York State Law requires all health care practitioners and facilities to allow patients to have access to their health records. However, some restrictions may apply. This form describes your rights, what information is available and how to appeal if access to health records is denied.
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.