ALBEMARLE SQUARE FAMILY HEALTHCARE · ALBEMARLE SQUARE FAMILY HEALTHCARE . A Division of Anchor...
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ALBEMARLE SQUARE FAMILY HEALTHCARE A Division of Anchor Healthcare, PLC D. Andrew Macfarlan, MD – Mark D. Niehaus, MD – Deborah Campbell, MD Jane Shaw, MD – Mary Whittemore, MD - Kelly Maupin, FNP, Kimberly Carter, NP-C 416 Albemarle Square Charlottesville, VA 22901 434-978-2126 AUTHORIZATION FOR RELEASE AND/OR EXCHANGE OF HEALTH INFORMATION Patient Name:__________________________________________________________Date of Birth________________________ Present Address:__________________________________________________________________________________________ ______________________________________________________________Phone:____________________________________ I authorize the following medical office/physician to release and/or exchange my health information as follows: From Practice/Physician:____________________________________________________________________________________ ________________________________________________ ____________ ______________ __________________________ City State Zip Phone To/Recipient:_______________________________________ _________________________________________________ Name of Physician / Facility receiving records Mailing Address __________________________ ____________ __________ ________________________ ____________________ City State Zip Phone # Fax # Transfer of care Continuing Care Legal Insurance purposes Personal use Workers Comp Specific records/reports to be Disclosed (include dates if specific records are needed) Office Visits Billing Record Hospital Records Labs Radiology Reports Psychiatric Notes HIV/STD labs ALL RECORDS ***There is a charge for your medical records as allowed pursuant to Virginia Law of 50 cents per page for the first 50 pages; 25 cents per page from page 51 on, plus a $10.00 processing fee payable at the time of processing your request *** I understand that this authorization is voluntary. By signing below, I am giving my permission to the disclosure of confidential health care records to include if applicable, PSYCHIATRIC, DRUG/ALCOHOL, OR HIV TESTING/TREATMENT records and other information contained in my medical record, unless otherwise indicated above and that no claims or orders pending or in effect that prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected information. I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by federal privacy regulations. This authorization will expire six (6) months from the date of my signature; unless it is for the sole purpose of obtaining information for a research study. _________________________________________________________________________ __________________________ Signature of Patient or Patient’s representative Date _________________________________________________________________________ __________________________ Printed name of patient or Representative Relationship to patient
Transcript of ALBEMARLE SQUARE FAMILY HEALTHCARE · ALBEMARLE SQUARE FAMILY HEALTHCARE . A Division of Anchor...
ALBEMARLE SQUARE FAMILY HEALTHCARE A Division of Anchor Healthcare, PLC
D. Andrew Macfarlan, MD – Mark D. Niehaus, MD – Deborah Campbell, MD Jane Shaw, MD – Mary Whittemore, MD - Kelly Maupin, FNP, Kimberly Carter, NP-C
416 Albemarle Square Charlottesville, VA 22901
434-978-2126 AUTHORIZATION FOR RELEASE AND/OR EXCHANGE OF HEALTH INFORMATION
Patient Name:__________________________________________________________Date of Birth________________________
Present Address:__________________________________________________________________________________________
______________________________________________________________Phone:____________________________________
I authorize the following medical office/physician to release and/or exchange my health information as follows:
From Practice/Physician:____________________________________________________________________________________
________________________________________________ ____________ ______________ __________________________ City State Zip Phone
To/Recipient:_______________________________________ _________________________________________________ Name of Physician / Facility receiving records Mailing Address
__________________________ ____________ __________ ________________________ ____________________ City State Zip Phone # Fax #
Transfer of care
Continuing Care
Legal Insurance purposes
Personal use Workers Comp
Specific records/reports to be Disclosed (include dates if specific records are needed) Office Visits Billing Record Hospital Records Labs Radiology Reports Psychiatric Notes HIV/STD labs ALL RECORDS
***There is a charge for your medical records as allowed pursuant to Virginia Law of 50 cents per page for the first 50 pages; 25 cents per page from page 51 on, plus a $10.00 processing fee payable at the time of processing your request ***
I understand that this authorization is voluntary. By signing below, I am giving my permission to the disclosure of confidential health care records to include if applicable, PSYCHIATRIC, DRUG/ALCOHOL, OR HIV TESTING/TREATMENT records and other information contained in my medical record, unless otherwise indicated above and that no claims or orders pending or in effect that prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected information. I understand that once the information is disclosed pursuant to this authorization, it may be re-disclosed by the recipient and the information may not be protected by federal privacy regulations. This authorization will expire six (6) months from the date of my signature; unless it is for the sole purpose of obtaining information for a research study.
_________________________________________________________________________ __________________________ Signature of Patient or Patient’s representative Date
_________________________________________________________________________ __________________________ Printed name of patient or Representative Relationship to patient
ALBEMARLE SQUARE FAMILY HEALTHCARE D. Andrew Macfarlan, M.D. – Mark D. Niehaus, M.D. - Deborah Campbell, M.D. - Jane Shaw, M.D. – Mary Whittemore, M.D.
Kelly Maupin, FNP – Kimberly Carter, NP-C 416 Albemarle Square, Charlottesville, VA 22901
434-978-2126
_______________________________________________________ ______________________________________ Signature of Patient or Personal Representative Date
Name of Patient: Date of Birth: _
Albemarle Square Family Healthcare is authorized to release protected health information about the above patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient's instructions.
Entity to receive information. Description of information to be released. Check each person/entity that you approve to Check each box that can be given to person/entity on the receive information. left in the same section.
□ Voicemail □ Results of lab tests/radiology.
Phone # _______________________________ □ Other:________________________________________
□ Spouse (provide name and contact number) □ Financial □ All medical records
___________________________________________ □ Specific records ________________________________ ___________________________________________ ________________________________________________
□ Parent (provide name and contact number) □ Financial □ All medical records
___________________________________________ □ Other:________________________________________
___________________________________________ _______________________________________________
□ Other (provide name and contact number) □ Financial □ All medical records
___________________________________________ □ Other:________________________________________
___________________________________________ _______________________________________________ Patient information: I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient and may be updated each year.
Name
Past Medical History
DOB Date
MEDICATIONS (Including ALL over the counter meds and supplements): Name Dose Directions
ALLERGIES: Medication/Food:______________________ Reaction:__________________________________________________
Medication/Food:______________________ Reaction:__________________________________________________
Medication/Food:______________________ Reaction:__________________________________________________
Medication/Food:______________________ Reaction:__________________________________________________
Medication/Food:______________________ Reaction:__________________________________________________
Medication/Food:______________________ Reaction:__________________________________________________
Adult Past Medical 2017
Is there any additional information you would like to provide?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
