Understanding the intricacies of the MR-201 form is crucial for patients who wish to authorize the release of their medical information to a third party. This form plays a pivotal role in ensuring that healthcare providers, insurance companies, attorneys, or any other designated entities can access specific health records for various reasons, be it for ensuring continuity of care, legal matters, or insurance claims. It encompasses a range of information, from basic patient identification details, such as name and address, to more specific directives regarding the type of records to be released, including emergency room visits, hospitalizations, and even sensitive information like HIV-related data. With provisions for specifying exclusions, the form recognizes the patient's autonomy over their medical history. Furthermore, it highlights the non-contingent nature of medical treatment or payment upon the patient's consent to release records, emphasizing patient rights and medical ethics. The form also delineates the process for revocation of consent, underscoring the patient's ongoing control over their personal health information. Importantly, it acknowledges the potential for redisclosure by the recipient, which might not be protected under federal health information privacy regulations—shedding light on the nuances of privacy and the flow of confidential information in the healthcare ecosystem.
| Question | Answer |
|---|---|
| Form Name | Form Mr 201 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Huntington, mr 201 form, HIV, Sinai |
PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO THIRD PARTY
Patient’s
Name: _____________________________________________________________________________________
(Last) |
(First) |
(Middle) |
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Date of |
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Unit Number: ________________ |
Birth: __________________ |
Tel. No.:___/_____/___________ |
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Month/Day/Year |
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Address: ____________________________________________________________________________________
(Street) |
(City) |
(State) |
(Zip Code) |
Please request/check all that apply:
I authorize Mount Sinai to disclose medical information about my:
o Manhattan o Queens o Huntington
___Emergency Room visit on: __________________________________________________
Date(s)
___OPD Clinic visit, specify clinic: _______________________________________________
Date(s)
___FPA Practice/Provider_______________________________________________________
Name of ProviderDate(s)
___ Hospitalization from: __________________________ to __________________________
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Admission Date(s) |
Discharge Date(s) |
___ Ambulatory Surgery: |
Date: ________________________ |
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____Specify (i.e. Lab tests, Operative Reports)______________________________ Date____________
Records to be disclosed ____ do include ____ do not include HIV
To o Healthcare Provider |
o Insurance Company or Designee |
o Attorney |
|
o Court |
o Law Enforcement |
o Employer |
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Other: _______________________________________________________________________
Name: _____________________________________________________________________________
Address: ___________________________________________________________________________
Reason for Disclosure o Patient Request |
o Other: ____________________________________ |
We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign we will not release your records.
1 – Medical Record Copy |
2- Patient Copy |
I understand that this authorization is valid for one year from this date or until __________________and may be
revoked by me at any time except to the extent Mount Sinai has already taken action based on my authorization.
SPECIFIC UNDERSTANDINGS
I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or Psychiatric records and or
If I am authorizing the release of
By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above. This information may be redisclosed if the recipient(s)as described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.
Patient |
|
Signature: ___________________________________ |
Date: ___________________________________ |
Personal Representative |
|
Signature: ________________________________ |
Print Name: ______________________________ |
Authority: ________________________________ |
Tel. No: _________________________________ |
Address: ________________________________ |
Date: ___________________________________ |
{Personal Representative to sign only if patient is a minor or incompetent}.
To request records or to revoke authorization send a written request to:
Mount Sinai Hospital |
Faculty Practice Associates |
Medical Records |
Patient Rights Coordinator |
One Gustave L. Levy Place – Box 1111 |
One Gustave L. Levy Place – Box 1621 |
New York, NY 10029 |
New York, NY 10029 |
Mount Sinai Hospital Queens |
Northshore Medical Group |
Medical Records |
Medical Records |
Huntington, NY |
|
Long Island City, NY 11102 |
|
For Mount Sinai Use Only |
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Date Received: (MO/DY/YR) _________/________/_________
Disposition of Request: __________ GRANTED ________ DENIED _________ PARTIALLY DENIED
Patient Notified in Writing Of Response On This Date: (MO/DY/YR) _______/______/________
Fee Charged For Fulfilling This Request (if applicable): $ ________________
Name or Initials of Records Department Staff Member Processing This Request: ________________________
¨ Mail Out |
¨ Will Pick Up |
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1 – Medical Records Copy |
2 – Patient Copy |
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