Solicitud de Información

AUTHORIZE NEW HORIZON HEALTH CENTER THE REQUEST OR RELEASE OF PATIENT'S PROTECTED HEALTH INFORMATION (PHI) BY COMPLETING AND SUBMITTING THE FORM BELOW.

FOR MORE INFORMATION CONTACT THE HEALTH INFORMATION DEPARTMENT AT 956-548-7400 EXTENSION 1255

First Name

Middle Name

Last Name

Date of Birth

Maiden Name

PATIENT'S MAILING ADDRESS

PATIENT'S PHONE NUMBER

PATIENT'S EMAIL ADDRESS

PATIENT'S FAX NUMBER

WHAT REQUEST OR AUTHORIZATION TYPE YOU LIKE TO MAKE:

(USE ONE OF THE OPTIONS BELOW)

SECTION A - I am authorizing NHHC to Send my medical records To :

SECTION B - I AUTHORIZE NHHC TO OBTAIN/REQUEST INFORMATION FROM :

Please enter the reason for the disclosure of your medical information:

If there are specific diagnosis, treatment, treatment dates, or other details you want shared, please enter them below.

I KNOW THAT MY WRITTEN CONSENT IS NEEDED TO RELEASE ANY PROTECTED HEALTH INFORMATION RELATING TO TESTING, DIAGNOSIS, AND/OR TREATMENT FOR HIV (AIDS VIRUS), SEXUALLY TRANSMITTED DISEASES, PSYCHIATRIC DISORDERS, MENTAL HEALTH, OR DRUG OR ALCOHOL ABUSE. IF I HAVE BEEN TESTED, DIAGNOSED, OR TREATED FOR ANY OF THE ABOVE-NAMED CONDITIONS, YOU ARE AUTHORIZED TO RELEASE HEALTH CARE INFORMATION RELATING TO SUCH DIAGNOSIS TESTING, OR TREATMENTS, PLEASE ENTER PATIENT'S OR PATIENT'S REPRESENTATIVE INITIALS BELOW:

Patient's or Representative's Initials :

PLEASE ENTER THE DATE OR EVENT THAT DETERMINES THE END OF YOUR CONSENT (I.E. RESEARCH END)

I KNOW THAT I HAVE THE RIGHT TO WITHDRAW THIS AUTHORIZATION, IN WRITING, AT ANY TIME BY SENDING SUCH WRITTEN NOTICE TO THE NHHC HEALTH INFORMATION MANAGEMENT DEPARTMENT OR COMPLIANCE OFFICE. I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION. MY REFUSAL WILL NOT AFFECT MY ABILITY TO OBTAIN TREATMENT OR PAYMENT OR ELIGIBILITY FOR BENEFITS. I ALSO KNOW THAT INFORMATION USED OR DISCLOSED BEFORE THIS AUTHORIZATION MAY BE SUBJECT TO RE-DISCLOSURE BY THE PERSON WHO RECEIVED THE INFORMATION AND MAY NO LONGER BE PROTECTED BY STATE OR FEDERAL LAW.

Your Signature

IF YOU AGREE WITH THE ASSERTIONS BELOW CLICK SUBMIT : Obligatorio

I HAVE READ AND ACKNOWLEDGE ALL THE ABOVE STATEMENTS.

I DECLARE THAT THE INFORMATION I'VE PROVIDED IS ACCURATE AND COMPLETE.

Your submission has been received. We may contact you for Verification.

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