Beaver Bmg Mr 300 Form PDF Details

The beaver Bmg Mr 300 form is an important piece of equipment for any business that wants to make a good impression with its customers. This form can be used to provide customers with information about the products or services they are interested in, and it can also be used to collect feedback from customers about their experience with your company. By using the beaver Bmg Mr 300 form, you can ensure that your customers have a positive experience with your business.

QuestionAnswer
Form NameBeaver Bmg Mr 300 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbeaver medical records, BMG-MR-300, SSN, CFR

Form Preview Example

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

X-ray reports

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.

BMG-MR-300 (10/06)

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 re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPPA). The recipient of this information is requested not to re-disclose this information without my authorization for disclosure. Beaver Medical Group, its employees, officers, and physicians are hereby released from any legal responsibility or liability for improper re-disclosure of the above information to the extent indicated and authorized herein.

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

TERRACINA-Peds TERRACINA -PT TERRACINA-Ortho