Health Forms Here is a collection of helpful, downloadable health forms. You may also deliver the completed form in person to the department from which you would like to request information. endstream endobj 363 0 obj <. Washington University Health Information—Release Services . There may be a $25 fee. 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. 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. It may be obtained from multiple paper-based or electronic-based forms (as applicable). University of Washington 1959 N.E. Item #3 (Records to be released from): identify the holder of records to be released are for services provided. Box 356500 Seattle, WA 98195-6500 The Family Educational Rights and Privacy Act (FERPA), is a federal law that governs the use of, and limits access to student educational records. 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. If the release has been accomplished, you will be notified by a representative of the Health Information staff. CANARY - PATIENT New Patient Forms – Outpatient Psychiatry Clinic 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. Use this form to request a replacement for a Financial Aid/Refund check. Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center University of Washington Physicians Seattle, Washington. 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. 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). 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. UH2078 REV JAN 20 . 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. Please use the following options to reach us to provide services to you: (608) 263-6030, Select Option 5 You can also use this form to request medical records from Hall Health/UW Medicine. It requires the Secretary of Health to adjust the amounts biennially in accordance with changes in the Consumer Price Index. 4. Radiology Images Phone: 206.860.5496, Option 3 Fax: 206.860.4539 *Note: Requests can take up to 15 business days to process. 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 REQUEST AMENDMENT OF MED RECORD . Access from Tuition Charge Statement on MyUW. Medical Records Release Please be aware that we are NOT the office that releases medical records. 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. Office Phone: 314-273-0453 Fax: 844.868.1435 • The revocation will not apply to information already released in response to this authorization. Please be aware that other authorizations may handle these protected conditions differently. ; Imaging Records Release: Use this form if you’d like your diagnostic imaging data and reports released to another medical facility. Marysville Family Medicine. Item #1 (Patient Information): The name, birthdate, phone number and Medical Record Number (if known) of the patient. Complete and return them as requested by your care team before your UW Medicine hospital or clinic visit. Release of Patient Information Each UW Medicine entity has a department that is responsible for appropriately disclosing patient information. It may include data elements from outside sources that are embedded in tables and documents. The release will be revoked for any further disclosure. 395 0 obj <>stream Patient’s Ability to Sign. 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. Allowable charges for copies of medical records. If you have any questions concerning the cancellation process, call the Health Information Management (Medical Record) Department (425) 339-5426 extension 2171 or 2321. 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 Consent for Release of Information. Forms: Health Services Release of Information; Counseling Services Release of Information; Allergy Injection Agreement; No Show Appeal Form Medical Release. Provided are links to the forms that you may need for your appointment. 5. This authorization will also allow these individuals to obtain information about your tuition charges over the phone, by email or in-person. %%EOF For Valley Medical Center patient forms, please visit the VMC website. 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. Home / Medical Center / Medical Records Release Form ... Washington Regional Medical Center 3215 N. Northhills Blvd. endstream endobj startxref Campus Box 1219 . PLACE PATIENT LABEL HERE UW Medicine Harborview Medical Center – University of Washington Medical Center UW Neighborhood Clinics – Valley Medical Center Fax: (425) 690-9407 Phone: (425) 690-3406 . Please read and complete the entire form in order for UW Medicine to process this request . Pacific St. PHQ-9 Form; GAD-7 Form; Medical Records. Contact UW Medicine’s Medical Records Department at 206.744.9000. Get help. UW Medicine is a premier healthcare system that integrates comprehensive patient care and nationally ranked research for over 300 medical clinics. Item #2 (Purpose): indicate any and all purposes for disclosure. 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 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. Advance Directives: Advance directives are legal documents used to communicate your preferences about future health care. Below you’ll find forms that may be applicable to your primary or specialty care appointment or procedure. 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. Authorization to Release Medical Records; Request digital copies of radiology images; Contact: Medical Records Phone: 920.784.2482 Fax: 920.593.3029. Instead, complete and mail form SSA-7050-F4. Each office has an individual process to authorize users to view student information. Do not use this form to: • Request the release of medical records on behalf of a minor child. St. Louis, MO 63110 . Chapter 70.02 RCW sets regulations regarding health care information access and disclosure. Telehealth Patient Info Sheet and Zoom User Guide Such forms are available at the Marketing & Public Affairs web page of the UW Health intranet. Please complete these forms and have them handy to discuss with your provider. 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. Find a doctor or book an appointment online.