Hch 551 Form PDF Details

When navigating the nuances of accessing or distributing healthcare information, the Hch 551 form plays a significant role, serving as a crucial tool for patients who need to authorize the procurement or sharing of their health records. This form caters to various situations where medical information needs to be transferred between parties, such as for continued care, legal matters, insurance claims, or personal reasons. The comprehensive form enables patients to stipulate exactly what parts of their medical history can be disclosed, ranging from abstracts of medical records to more specific documents like laboratory test results or emergency department records. It is designed with the patient's privacy in mind, allowing them to exclude sensitive information like mental health treatment, HIV testing results, or substance abuse records from being shared. The authorization process facilitated by the Hch 551 form requires patients to clearly print their personal details, specify the recipient of the information, and detail the purpose of the request. A notable aspect of the form is its emphasis on patient autonomy and confidentiality, underscoring that treatment at UConn Health is not contingent upon the patient's decision to sign the authorization. Furthermore, the form includes provisions for minors, fees for record copies, and the conditions under which the authorization can be revoked, highlighting the careful consideration given to protecting patient rights and ensuring informed consent.

QuestionAnswer
Form NameHch 551 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshch form, uconn obtain information pdf, uconn connecticut hch, 551 health form

Form Preview Example

 

 

 

 

 

 

 

 

(Patient Identification)

 

 

 

 

Authorization to Obtain and/or Disclose Health Information

 

 

 

 

 

 

 

 

______________________________

___________

 

Patient Name

: _________________________________

 

 

 

(Last)

 

(First)

 

 

(

Middle Initial)

 

 

 

 

 

___________________________________________________

 

Date of Birth

: _______________________________

(Previous Name(s))

 

 

 

 

 

 

 

 

 

 

 

 

Apt/Unit:

City:

State:

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

Complete Address

(PLEASE PRINT CLEARLY)

 

 

 

 

 

 

 

Phone:____________________________(

HOME CELL WORK) Email:______________________________

Ihereby authorize UConn Health (if obtaining, Department Name: ____________________ Mail Code: _________

Address: __________________________________________________________________________________

to disclose information from my medical record to: and/or to obtain information from:

Name: _________________________________________________________________________________________________

Address: _____________________________________________________________ City: ______________________ State: ______ Zip: _____________

Phone: ________________________________________ Fax:_____________________________________

I authorize the following protected health information (PHI) to be obtain/disclosed from my medical record(s):

Date(s) of Service or Date Range______________________________________________________________

Abstract of Medical Record (History & Physical, Discharge Summary, ED Record, Operative Report(s), Pathology Results,

Lab Results, Radiology Results, Consultation Report(s))

 

Discharge Summary

History & Physical/Admit Note

Radiology reports

Laboratory test results

Pathology Result(s)

Consultation report(s)

Pulmonary Function test result(s)

Echocardiogram/EKG

Immunization Record

Emergency Department record

Outpatient Clinic/Office Note(s)

Dental Clinic note(s)

Rehabilitation Dept./PT/OT notes

Cardiac Testing Result/Stress Test

Operative/Procedure Report(s)

Itemized Bill

Radiology films (requests processed by Film Library)

Complete record (includes all above if applicable, plus nursing notes, ancillary notes, all testing, and consents.) Other (please specify):

I do not authorize disclosure of the following:

Alcohol, Drug, or Substance Abuse Treatment Records

HIV Testing

Behavioral Health Treatment Records

Genetic Testing

The purpose for requesting information

:

Legal

Insurance

Personal

Continuation of Care

Disability/SSA

Veteran’s Benefits

Other (please specify other on line below):__________________________________________

For release to PATIENTS only specify:

Paper Copies

Electronic format_____________________________________

Paper copies will be provided unless otherwise specified

* HCH5 5 1 *

HCH-551 Eff.7/03 Rev.7/04,9/06,8/11,1/12,9/13,1/16,6/16,10/17,5/18,9/20 Page 1 of 2 DS C

(Patient Identification)

Authorization to Obtain and/or Disclose Health Information

By signing this authorization form, I understand that:

•This authorization is voluntary and that my records may include protected information relating to AIDS, HIV testing and results, behavioral health treatment, treatment for alcohol ,drug and/or substance abuse.

•A patient whom is a minor (age 13 or older) must also sign the authorization, if medical records contain protected information with the exception of Behavioral Health, which requires authorization by the patient if a minor age 16 or older.

•Requests for copies of medical records are subject to fees as allowed by law.

•In cases where UConn Health is requested by a third party to create health information solely for sharing that information with the party that requested it, I understand that I must sign this authorization.

•I may change my mind and cancel (revoke) this authorization. I have the right to revoke this authorization at any time. This authorization may be revoked in writing to the Director of Health Information Management. It will not apply to information that has already been disclosed in response to this authorization.

•Unless otherwise revoked, this authorization will expire on the following date/event/condition:

_________________________________. If I fail to specify an expiration date/event/condition, this authorization will expire six (6) months from the date signed.

•I understand that the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations.

•I understand that my treatment or continued treatment by UConn Health is in no way conditioned on whether or not I sign this authorization and that I may refuse to sign it.

•I understand that I may inspect or copy the information to be used or disclosed and that I may receive a copy of this signed authorization.

•If this disclosure contains information relating to HIV, behavioral health, alcohol, drug and/or substance abuse treatment, the following shall apply: This information has been disclosed to you from records whose confidentiality is protected by law. Federal regulations (Title 42 CFR Part 2) and Connecticut General Statutes (Ch. 368x) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of psychiatric or substance abuse information is NOT sufficient for this purpose.

Return completed authorization via mail, fax or email (Patient use only) to:

Mailing Address:

UConn Health

 

 

 

 

 

 

Health Information Management

 

Release of Information MC2260

 

263 Farmington Ave

 

Farmington, CT 06030

ROI Office Fax Number:

860-679-1273

 

 

 

 

 

Email (For Patient Use only):

PatientROIRequests@uchc.edu

___

 

 

_____________

Signature of Patient or Authorized Representative

**

 

 

 

Date/Time

 

 

 

 

__

 

 

 

 

Printed name of Patient or Authorized Representative **

□Healthcare Representative □Conservator

Relationship to Patient: □Self □Parent

□ Legal Guardian

□Executor/Administrator of Estate □ Power of Attorney

□Other Authorized Representative: _________________________________

** A copy of the authorized representative’s legal authority to act on behalf of the patient must be attached.

Name and relationship to patient of individual authorized to pick up record(s) being released from the facility:

____________________________________

Questions? Please call 860-679-2787

HCH-551 Eff.7/03 Rev.7/04,9/06,8/11,1/12,9/13,1/16,6/16,10/17,5/18,9/20 Page 2 of 2 DS C

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This form will involve specific information; to guarantee consistency, please be sure to take heed of the following steps:

1. You have to fill out the hch form properly, so be mindful when working with the segments including these particular fields:

Step no. 1 for filling in uconn health information online

2. After filling out this part, head on to the subsequent stage and fill out all required details in these blanks - I authorize the following, Abstract of Medical Record History, Lab Results Radiology Results, Discharge Summary Laboratory test, Pulmonary Function test results, Rehabilitation DeptPTOT notes, History PhysicalAdmit Note, EchocardiogramEKG Outpatient, Radiology reports Consultation, Immunization Record Dental Clinic, Cardiac Testing ResultStress Test, OperativeProcedure Reports, Complete record includes all above, I do not authorize disclosure of, and Alcohol Drug or Substance Abuse.

Tips to complete uconn health information online portion 2

3. Throughout this step, take a look at Unless otherwise revoked this, If I fail to specify an, I understand that the information, I understand that my treatment or, I understand that I may inspect or, Return completed authorization via, Mailing Address, UConn Health Health Information, ROI Office Fax Number, Email For Patient Use only, PatientROIRequestsuchcedu, Signature of Patient or, and DateTime. All of these must be taken care of with highest accuracy.

uconn health information online writing process outlined (part 3)

4. This particular section comes with these empty form fields to complete: Printed name of Patient or, Relationship to Patient Self, A copy of the authorized, Name and relationship to patient, Questions Please call, and HCH Eff Rev Page of DS C.

Writing segment 4 in uconn health information online

People often get some things wrong when filling in A copy of the authorized in this area. Be certain to double-check everything you enter right here.

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