Form Orc 110 B PDF Details

In our increasingly digitized world, the privacy and accessibility of health records have taken center stage, bridging the gap between patient rights and healthcare administration. The ORC 110 B form, a crucial document within this landscape, serves as a tool for patients seeking access to their designated record set from Providence Healthcare facilities. This form allows individuals to request their health records in various formats, such as paper, disc, or secure email, covering a range of services from history and physical, operative reports, diagnostic reports including lab and X-ray, discharge summaries, emergency department reports, office visits, outpatient progress notes, to billing statements and CDs of diagnostic films. Specifically designed for residents in states such as Alaska, California, Montana, Oregon, and Washington, it encompasses requests for records spanning specified date ranges. Importantly, while the form facilitates access to essential health documentation free of charge for specific records, it also outlines the circumstances under which fees may be applicable, underscoring the balance between service accessibility and the operational needs of healthcare providers. Additionally, the form includes provisions for personal representatives to act on behalf of patients, reflecting a comprehensive approach to healthcare information management. The procedure for submitting the form is streamlined, with clear instructions for both patients and their representatives, including details on where and how to send the form, especially for those treated at multiple facilities or unsure about the appropriate contact information for Providence Health and Services.

QuestionAnswer
Form NameForm Orc 110 B
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical records request providence request record set form

Form Preview Example

PATIENT REQUEST FOR ACCESS TO A DESIGNATED RECORD SET

Patient's Last Name:

First Name:

Middle Initial:

DOB:

Other Name(s) Used:

Address:

City:

 

State:

ZIP:

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

For What States:

 

 

 

 

 

 

 

 

Alaska

Californa

Montana

Oregon

 

Washington

For the range of dates from:

 

 

to:

 

 

 

 

 

 

 

 

 

 

 

I would like to receive a copy of my records:

 

On Paper

 

On Disc

 

Secure Email

 

 

 

I am requesting records from the following Providence Facility(s):

Hospitals (List)

Clinics (List)

Packet provided free of charge:

History and Physical Operative Report Diagnostic Reports (lab, xray,etc.)

Discharge Summary Emergency Deptartment Report • Office Visits

•Outpatient Progress Notes

Billing Statement

CD of Diagnostic Film (Please provide Date of Service):

FEES MAY APPLY for following requests:

Entire Chart

 

 

Other (Specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient/Personal Representative

 

 

 

 

Sign Here:

 

Date:

Internal Use Only

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

(Print form and sign by hand)

Rec'd:_______________

 

If Personal Representative

 

 

 

 

 

ID Verified by:

 

 

 

 

 

 

 

 

 

Print name:

 

 

Print

 

 

 

 

Name:_______________

 

 

 

 

 

 

 

 

 

Description of Authority:

 

 

Signature:

 

 

 

 

_____________________

 

 

 

 

 

 

 

 

Revised: April 2013

Page 1 of 2

ORC 110-b

Important Information Regarding Obtaining Designated Record Set:

In some areas, Providence hospitals and clinics store patient records separately. The hospital or clinic staff would be glad to fax a copy of this form to other facilities for you upon request.

Please forward this form to the Medical Record Department of the Providence Healthcare facility at which you were seen. If you were seen at multiple facilities or are unsure of the appropriate contact information, you may forward the request to:

Centralized Release of Information Department

4400 NE Halsey Street, Building 1, Suite 286

Portland, OR 97213

Phone (855) 234-2491

Fax: (855) 234-2493

Important: Providence Health and Services no longer prints or releases patient social security numbers unless required for billing. However, social security numbers may be included in patient records that are more than a few years old. The records you are requesting may include your social security number.

Revised April 2013

Page 2 of 2

ORC 110-b

How to Edit Form Orc 110 B Online for Free

You are able to fill in Form Orc 110 B effectively with our PDF editor online. To have our editor on the forefront of efficiency, we strive to put into action user-driven features and enhancements on a regular basis. We are routinely pleased to get suggestions - help us with remolding how we work with PDF forms. Here's what you'd want to do to begin:

Step 1: Simply hit the "Get Form Button" above on this site to see our form editing tool. Here you will find everything that is necessary to work with your file.

Step 2: The tool allows you to modify your PDF in a range of ways. Change it with any text, adjust existing content, and include a signature - all within a couple of clicks!

As a way to fill out this form, make sure you enter the required information in each blank field:

1. You have to complete the Form Orc 110 B correctly, hence be mindful when filling in the parts that contain these fields:

Form Orc 110 B completion process outlined (step 1)

2. The next part would be to fill in these particular blank fields: Packet provided free of charge, History and Physical Operative, Billing Statement, CD of Diagnostic Film Please, FEES MAY APPLY for following, Entire Chart, Other Specify, PatientPersonal Representative, If Personal Representative, Print form and sign by hand, Date, and Internal Use Only Date Recd ID.

Writing part 2 of Form Orc 110 B

3. This next portion will be about If Personal Representative, Print name, Description of Authority, Internal Use Only Date Recd ID, and Revised April Page of ORC b - type in each of these blanks.

Revised April Page of ORC b, Internal Use Only Date Recd ID, and Description of Authority in Form Orc 110 B

People who use this document generally get some things wrong when filling in Revised April Page of ORC b in this part. Don't forget to read twice everything you type in here.

Step 3: Spell-check the details you've entered into the blank fields and then hit the "Done" button. Grab the Form Orc 110 B as soon as you subscribe to a 7-day free trial. Easily access the form in your FormsPal account, along with any edits and adjustments being automatically saved! When you work with FormsPal, you'll be able to complete documents without being concerned about information breaches or records getting distributed. Our secure platform helps to ensure that your personal data is kept safe.

Form Orc 110 B isn’t the one you’re looking for?

Related Documents