Office Phone: 314-273-0453 Fax: 844.868.1435 • The revocation will not apply to information already released in response to this authorization. 4. The University of Washington provides professional liability coverage to Pathology through a self-insurance program pursuant to RCW 28B.20.250 through RCW 28B.20.255, which is equivalent to or exceeds limits of at least $1,000,000 per occurrence/claim and $3,000,000 annual aggregate. Fayetteville, AR 72703. Grant permission, for those specified on the form, to access the student's account for information regarding tuition and loans. Health Forms Here is a collection of helpful, downloadable health forms. Questionnaires PLACE PATIENT LABEL HERE UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center UW Self Disclosure, Consent and Release of Information Form (PDF) HIPAA Training; Data stewardship and the UW PCISA form; Infection control training; BLS for healthcare providers; What to do in case of a needlestick/BBP exposure; Drug testing for select clerkship rotations; Immunizations; How to access your compliance documents; Vodcasts 362 0 obj <> endobj Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit. Copyright © 2021 University of Washington | All rights reserved, Notice of Privacy Practices Acknowledgment​, Patient Authorization for UW Medicine to Use or Disclose Protected Health Information for Publicity, Patient Authorization to Disclose, Release and/or Obtain Protected Health Information, Patient Authorization to Leave Personal Health Information by Alternate Means, Patient Authorization to Use and Disclose Protected Health Information for Publication, Patient Authorization to Use or Disclose Photography/Video, Request to Consider Additional Privacy Protection for Protected Health Information, Request for Correction or Amendment of the Medical Record, Request to Restrict Disclosure of Healthcare Items or Services to Health Plans When Patients Self-Pay Out of Pocket, Pediatric NICHQ Vanderbilt Assessment Scales: Used for Diagnosing ADHD, Medicare Subsequent Annual Wellness Visit, Permission to Treat a Minor Without a Parent/Guardian Present, Special-Needs Athlete Supplemental History, Authorization to Leave Personal Health Information by Alternate Means, Hand Foot and Ankle Institute Questionnaire, Female-male couple fertility new patient history, Female single or same-sex couple fertility new patient history, Dental clearance for kidney pre-transplant evaluation, Kidney transplant demographic information, Kidney transplant recipient selection criteria, Patient acknowledgement for kidney, pancreas or kidney-pancreas transplant, Transplant services blood pressure record, CT contrast injection patient questionnaire, Concussion Assessment Tool: Baseline Test, Evaluation for Metabolic Surgery to Manage Obesity Patient Questionnaire UH3008, Questionnaire on Eating and Weight Patterns UH3305, Primary Care Women's Health New Patient Intake, Women's Health Preventative Health Visit - Established Patient, Midwives Clinic at Northwest Outpatient Medical Center. The Family Educational Rights and Privacy Act (FERPA), is a federal law that governs the use of, and limits access to student educational records. It may be obtained from multiple paper-based or electronic-based forms (as applicable). Please read and complete the entire form in order for UW Medicine to process this request . Consent for Release of Information. Forms: Health Services Release of Information; Counseling Services Release of Information; Allergy Injection Agreement; No Show Appeal Form This authorization will also allow these individuals to obtain information about your tuition charges over the phone, by email or in-person. Page 1 of 1 *U2078* UH2078 WHITE – MEDICAL RECORD . Chapter 70.02 RCW sets regulations regarding health care information access and disclosure. Release of Patient Information Each UW Medicine entity has a department that is responsible for appropriately disclosing patient information. Pacific St. Please be aware that other authorizations may handle these protected conditions differently. St. Louis, MO 63110 . Telehealth Patient Info Sheet and Zoom User Guide Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington. You can also use this form to request medical records from Hall Health/UW Medicine. Please complete these forms and have them handy to review with your provider. Release of Information: The information released may be obtained from the medical record of UW Health. Such forms are available at the Marketing & Public Affairs web page of the UW Health intranet. Complete and print the Authorization for Exchange of Verbal and Written Information form (pdf) Mail the completed form to the following address: UW Health Health Information Management Attention: Release of Information 8501 Excelsior Dr., Room 101 Madison, WI 53717; Or fax the completed form to (608) 262-6663 Students have full access to their academic records by logging into their MyUW account, but access is limited or restricted to others. CANARY - PATIENT Patient’s Ability to Sign. Use this form to request a replacement for a Financial Aid/Refund check. 383 0 obj <>/Filter/FlateDecode/ID[<8A91E2A4C4CF25479B9963AEC5C9C4A1><915D320FED9AA94B925C263EF056D5D5>]/Index[362 34]/Info 361 0 R/Length 105/Prev 190044/Root 363 0 R/Size 396/Type/XRef/W[1 3 1]>>stream The release will be revoked for any further disclosure. If you have any questions concerning the cancellation process, call the Health Information Management (Medical Record) Department (425) 339-5426 extension 2171 or 2321. Form to request medical records or share medical information Read more about Release of Medical Information (ROI) and find the form you’ll need to give a parent, partner or other family member access to your medical record. There may be a $25 fee. 395 0 obj <>stream Street P.O. General UW Medicine. Item #3 (Records to be released from): identify the holder of records to be released are for services provided. A medical release form can only be completed by a patient who is sound in mind and body. INFORMATION • NOTE that if an authorization is needed for disclosure of a patient’s medical information for purposes of fundraising or marketing, a separate form is required. Instead, complete and mail form SSA-7050-F4. Instead, visit your local Social Security office or call our toll- free number, 1-800-772-1213 (TTY-1-800-325-0778), or • Request detailed information about your earnings or employment history. Item #2 (Purpose): indicate any and all purposes for disclosure. Forms Mailing address: University Health & Counseling Services 800 W. Main Street Whitewater, WI 53190 UHCS Medical Records FAX: 262-472-5608 UHCS Counseling Records FAX: 262-472-1435. UW Medicine is a premier healthcare system that integrates comprehensive patient care and nationally ranked research for over 300 medical clinics. %PDF-1.6 %���� Aid Check Replacement. h�bbd```b``�"g�I�2,^&=@$�N0 �5��`RL~��H� r�'�dl�63D��uA�Y��{������'H(C&���q�7� �OK Access from Tuition Charge Statement on MyUW. Contact UW Medicine’s Medical Records Department at 206.744.9000. Your health and safety is our top priority.Testing | Patient safety | Care and services | Visitor policy | COVID-19 vaccine. Patient Request to Access a Designated Record Set Advanced Manual Therapy and Sports Rehabilitation Clinic. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file.This document allows a patient to list the names of family members, friends, clergy, health care providers, or other third (3rd) parties to whom they wish to have made their medical information available. endstream endobj 363 0 obj <. UW Medicine eCare is a free, secure and convenient way to access many types of personal health information in your inpatient or outpatient medical records, including test results, medical history, medications, immunizations and more. %%EOF Department of Orthopaedics and Sports Medicine. Adult Preventative Care 2018; New Patient Packet; Integrative Medicine Intake Form; Consent to Treat a Minor; Release of Information; FMLA Disability Information Worksheet; Snohomish Family Medicine. For Valley Medical Center patient forms, please visit the VMC website. Radiology Images Phone: 206.860.5496, Option 3 Fax: 206.860.4539 *Note: Requests can take up to 15 business days to process. Email: Recordsrequest@valleymed.org. Allowable charges for copies of medical records. Please note: The UW Health authorization does authorize release of records containing psychiatric diagnoses or treatment, alcohol or drug abuse information, or HIV or AIDS information, unless you specify any exceptions on the line above the signature line. It may include data elements from outside sources that are embedded in tables and documents. Please complete these forms and have them handy to discuss with your provider. Fax: (425) 690-9407 Phone: (425) 690-3406 . Release of Information Authorization Forms Authorization to Use, Disclose and Release Protected Health Information Complete this form to authorize Providence to disclose a copy of your protected health information to someone other than yourself. Students are able to authorize online access to their statement for up to five people by logging on to MyUW and completing the online Information Release Authorization. Box 356500 Seattle, WA 98195-6500 It requires the Secretary of Health to adjust the amounts biennially in accordance with changes in the Consumer Price Index. If the release has been accomplished, you will be notified by a representative of the Health Information staff. 5. RCW 70.02.010(37) defines the “reasonable fee” that may be charged for duplicating or searching the record. Advance Directives: Advance directives are legal documents used to communicate your preferences about future health care. PHQ-9 Form; GAD-7 Form; Medical Records. Find a doctor or book an appointment online. Employee Health Clinic. New Patient Forms – Outpatient Psychiatry Clinic University of Washington 1959 N.E. Each office has an individual process to authorize users to view student information. ; Imaging Records Release: Use this form if you’d like your diagnostic imaging data and reports released to another medical facility. COVID-19 UPDATE: During the COVID-19 virus pandemic, where we are practicing physical distancing to reduce the risk of community spread of the virus, the Health Information Management team will not be taking walk-in requests for records at the 8501 Excelsior Drive location.. Box 50010 Renton, WA 98058. Washington University Health Information—Release Services . Complete the Release of Information form and submit it by mail, fax, or email to UW Medicine’s Medical Records Department (see contact information above). endstream endobj startxref If you need a copy of a medical record from UW Medical Center, Harborview Medical Center, or the Neighborhood Clinics, please visit their website or contact Release of Information directly at 206-744-9000 or fax 206-744-9997. REQUEST AMENDMENT OF MED RECORD . This webpage is designed to be a reference for parents and family members who are interested in learning more about access to academ… 4240 Duncan Ave., Suite 301 . Get help. Provided are links to the forms that you may need for your appointment. UH2078 REV JAN 20 . Marysville Family Medicine. Authorization to Release Medical Records; Request digital copies of radiology images; Contact: Medical Records Phone: 920.784.2482 Fax: 920.593.3029. Authorization to Release Protected Health Information to a Third Party - MC0072-01 Instructions: This form is to be used by a patient or legal representative to authorize the release of information to a third party (other than a family member or friend) such as an insurance company, employer, or … h�b```f``����� �A��2�,M7������X�gK v�a�h ��10�/��@, e`8��Ƥ���%����!���9̿���|iHb`���p�L��.�#�Ja��� ;�̏p�H20=5Ҍ@�` �� Please use the following options to reach us to provide services to you: (608) 263-6030, Select Option 5 UW Medicine will disclose only the minimum amount of PHI necessary to accomplish the purpose of a given request for the use and disclosure of patient information for research. All UW Medicine workforce members are encouraged to refer requestors of patient information to their entity department to process requests for disclosure of patient information. Home / Medical Center / Medical Records Release Form ... Washington Regional Medical Center 3215 N. Northhills Blvd. 0 You may also deliver the completed form in person to the department from which you would like to request information. If you have a reason to think to patient isn’t mentally capable of making the decision to release medical information, or if they have a physical condition (like intense pain) that might influence their decision-making abilities, you can’t accept the release form. Campus Box 1219 . Item #1 (Patient Information): The name, birthdate, phone number and Medical Record Number (if known) of the patient. Provided are links to the forms for you to review prior to your initial appointment. Do not use this form to: • Request the release of medical records on behalf of a minor child. UW Medicine IT Services - Identity & Access Management (IAM) Mission: UW Medicine Information Technology Services’ Identity & Access Management (IAM) provides UW Medicine Account administration, support, and subject matter expertise regarding clinical and business systems in accordance with University of Washington and UW Medicine policies and State and Federal regulations. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit. Medical Records Release Please be aware that we are NOT the office that releases medical records. Provided are links to forms for patients who are seeing a provider at the UW Outpatient Psychiatry Clinic. Below you’ll find forms that may be applicable to your primary or specialty care appointment or procedure. Medical Release. UW Medicine . Mail: Release of Information 400 S. 43. rd. 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