Navigating through the complexities of medical information sharing, the Beaver Medical Group's MR 300 form represents a structured approach to handling sensitive health records. It is a pivotal document, designed with a clear purpose: to facilitate the authorized exchange of a patient's health information between different entities. This process is meticulously detailed, starting with the patient's consent for Beaver Medical Group to disclose their health records. The form is divided into distinct sections, each with its role in the process. From patient data and the parties involved in the exchange to the specifics of the information being released and the duration of the authorization. Noteworthy is the inclusion of protections and rights for the patient, emphasizing voluntary participation, the ability to revoke consent, and the safeguards against unauthorized re-disclosure. Moreover, attention is given to sensitive information such as HIV status, mental health, and substance abuse treatment records, which are subjected to additional layers of discretion. The document underscores the gravity of privacy and ethical considerations in the transfer of medical information, ensuring that such exchanges are conducted within a framework that respects the patient's autonomy and confidentiality. With provisions for the expiration of the authorization and detailed instructions on how patients can manage their consent, the MR 300 form is a comprehensive guide for transparent and responsible health information exchange.
| Question | Answer |
|---|---|
| Form Name | Beaver Bmg Mr 300 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | beaver medical records, BMG-MR-300, SSN, CFR |
BEAVER
MEDICAL GROUP, L.P.
I hereby authorize Beaver Medical Group to disclose the health records of the patient listed below:
PRINT CLEARLY:
AUTHORIZATION TO
RECEIVE OR RELEASE
MEDICAL INFORMATION
or receive the following information from
SECTION A PATIENT DATA
SECTION B RELEASE FROM / TO
Patient Name: |
SSN: |
Phone #: |
Date of Birth: |
Release Information To: |
Receive Information From: |
Person/Organization: |
Person/Organization: |
Address: |
Address: |
City/State/Zip: |
City/State/Zip: |
Phone #: |
Phone #: |
Fax#: |
Fax#: |
Purpose of Disclosure: ■ Personal Access |
■ Continued Care ■ Other (Describe) |
SECTION C RELEASE DATA
_____________________________________________________________________
A separate authorization is required to authorize the disclosure or use of psychotherapy notes and HIV test results.
The type of records and the dates of service to be released or disclosed is as follows () check all that apply:
■Entire record (including Alcohol/drug treatment information)
■Entire record (excluding Alcohol/drug treatment information)
■ Billing information |
■ Problem list |
■ Medication list |
■ Immunization records |
■ Laboratory results |
■ |
■Mental health records (excluding psychotherapy notes)
■Other diagnostic (specify) __________________________________________
■Other__________________________________________________________
■Limitation of release ______________________________________________
Date(s) of Service _____________________________________________________
I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
SECTION D |
DURATION |
|
|
|
|
SECTION E |
AUTHORIZATION |
|
|
EXPIRATION
This authorization will automatically expire six months from the date of execution unless otherwise noted: ____________________________________
YOUR RIGHTS
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.
I may inspect or obtain a copy of the health information to be used or disclosed, as provided by 45 CFR 164.508(d)(1), (e)(2).
I have a right to receive a copy of this authorization.
I may revoke this authorization at any time, but I must do so in writing and submit it to:
Beaver Medical Group, Medical Records Department, 2 W. Fern Avenue, Redlands, CA 92373. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization.
I understand that information disclosed pursuant to this authorization could be re- disclosed by the recipient. Such
A copy or photocopy of this authorization will serve the same validity as though an original had been presented.
_______________________________________________________________________
Signature of Patient or Legal Representative
__________________________________________ |
______________________ |
Print Name |
Relationship |
_____________________________________________________________________
Address/State/Zip (if other than patient)
_____________________________ |
______________________ |
Phone # (if other than patient) |
Date Signed |
__________________________________________ |
______________________ |
Signature of Witness |
Date |
SECTION F OFFICE USE ONLY
Authorization Received by: ___________________________ Date: ______________
Patient/Representative Identification: ________________ Verified by: _______________
A copy of this authorization was offered/received by the patient.
Chart Location (): ■ Redlands ■ Highland ■ YUCAIPA ■ Banning ■ CoLTON
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