Form Sl 0427 PDF Details

In today’s rapidly evolving healthcare landscape, the confidentiality and management of Protected Health Information (PHI) stand paramount, and navigating the permissions related to the sharing of such sensitive data requires careful attention. The SL-0427 form, a crucial document employed by healthcare providers such as St. Luke's Hospital, serves as a streamlined method for patients to authorize the release of their medical records to designated individuals or entities. This form encompasses a wide array of medical details, including but not limited to, comprehensive medical records, discharge summaries, laboratory results, and even images like photographs or digital media. Importantly, it addresses the release of sensitive information concerning HIV/AIDS status, substance abuse treatment, and mental health care, giving patients the discretion to exclude these from disclosure. The form respects patient autonomy by allowing revocation of authorization at any time, establishing clear boundaries for both the duration of the authorization and the handling of the information post-disclosure. Accommodating the needs of patients and aligning with legal standards, the SL-0427 form also outlines potential fees for copying records, ensuring compliance with state and federal regulations. By signing the SL-0427, a patient not only navigates the complexities of PHI sharing but also enforces their rights and expectations regarding the privacy and handling of their medical information.

QuestionAnswer
Form NameForm Sl 0427
Form Length1 pages
Fillable?Yes
Fillable fields37
Avg. time to fill out7 min 43 sec
Other namesdisclosed, pursuant, Consents, herein

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION FOR USE AND DISCLOSURE OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROTECTED HEALTH INFORMATION (PHI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please print

 

 

 

 

Social Security Number:

 

 

 

Date of Service:

 

 

Purpose of Request:

 

 

 

 

 

 

 

 

I,

 

 

hereby authorize St. Luke’s Hospital to release my medical records to:

Name of Person/Organization

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

I specifically authorize the use and disclosure of the following:

 

 

 

 

£ Complete medical record(s)

 

OR £ Discharge Summary

£ Progress Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

£ History & Physical Examination

£ Laboratory Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

£ Consultation Reports

£ Radiology Reports

£Photographs, videotapes, digital or other images

£Other (please specify):

The information to be used or disclosed pursuant to this authorization may include information relating to: (1) AIDS or HIV infection; (2) treatment of drug or alcohol use; or (3) mental or behavioral health or psychiatric care.

Please DO NOT RELEASE any information, that has been checked below, if it appears in the record.

£ AlcoholAbuse

£ Drug Abuse

£ Psychological / Psychiatric conditions

£ AIDS / HIV results

I may revoke this authorization in writing at any time. I understand that such revocation will not have any effect on the information already used or disclosed by St. Luke’s Hospital before receiving my written notice of revocation. Unless earlier revoked, this Authorization will expire one year from the date it was signed or otherwise specified. I may request to inspect or copy the information that the hospital intends to disclose. I may refuse to sign this Authorization. St. Luke’s Hospital does not require you to sign the authorization to receive treatment. Once release of this information is made to the above named person/organization, my information may be subject to re-disclosure by the recipient.

St. Luke’s Hospital may assess appropriate and reasonable fees for the copying of such information if I am requesting information for myself or for a third party. Such fees will comply with state and federal laws.

I have read the above information and authorize St. Luke’s Hospital to disclose the identified information to the person/ organization and for the purpose described herein. I understand that, by signing this document, I release and discharge St. Luke’s Hospital from any liability and will hold St. Luke’s Hospital harmless for any release made pursuant to the Authorization.

Signature:Date:

Relationship to patient:

AUTHORIZATION FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION (PHI)

Page 1 of 1

St. Luke’s Hospital

232 S. Woods Mill Road Chesterfield, MO 63017

Form No. SL-0427

Consents TAB

Rev. 04/03

How to Edit Form Sl 0427 Online for Free

The PDF editor was made with the intention of allowing it to be as effortless and easy-to-use as it can be. The next steps are going to make filling up the Lukes quick and simple.

Step 1: Select the button "Get Form Here" and click it.

Step 2: So, you're on the file editing page. You can add content, edit existing details, highlight specific words or phrases, put crosses or checks, add images, sign the template, erase unneeded fields, etc.

For each area, add the content required by the platform.

expire gaps to fill in

In the part Date, Date, Time, and Time write down the details that the application demands you to do.

Filling in expire part 2

Step 3: If you are done, select the "Done" button to export the PDF form.

Step 4: You may create copies of your form toprevent all of the possible future troubles. Don't be concerned, we cannot disclose or check your data.

Watch Form Sl 0427 Video Instruction

Please rate Form Sl 0427

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .