Mclean Hospital Form 1668 PDF Details

Understanding the specifics of the McLean Hospital Form 1668 is essential for anyone involved in the release of healthcare information at this renowned facility. Located at 115 Mill Street, Belmont, MA, McLean Hospital offers this form to manage the authorization of healthcare information sharing effectively. The form is meticulously designed to address various types of information exchanges, including verbal updates, discharge summaries, and more detailed treatment reports, ensuring that patient confidentiality is upheld while facilitating necessary communications between healthcare providers, patients, and authorized third parties. It clearly outlines the purpose of the information release, whether for treatment, financial reasons, personal use, or other specified needs. Additionally, the form emphasizes the patient's autonomy, offering the option to withdraw consent at any moment and highlighting the right to refuse signing, which reassures patients that their treatment or benefits won't be adversely affected. Furthermore, it brings attention to specific areas such as mental health information, substance abuse treatment, HIV information, and counseling details for victims of domestic violence or sexual assault, acknowledging the sensitive nature of these records. By encompassing various checks and balances, including specifying the recipient of the information and the potential application of copying fees, McLean Hospital's Form 1668 stands as a comprehensive tool for handling healthcare information with the precision, respect, and confidentiality it deserves.

QuestionAnswer
Form NameMclean Hospital Form 1668
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmclean release information form 1668 rev 10 2011 mclean hospital medical records fax form

Form Preview Example

3-HOLE

Health Information Management

115 Mill Street, Mail Stop 139, Belmont, MA 02478-9106

Telephone 617.855.2447

AUTHORIZATION FOR RELEASE OF HEALTHCARE INFORMATION

5/16 4 1/4 C-TO-C

Patient Name:

Specific information to be released:

Verbal Information/Telephone Update

Discharge/Treatment Summary

Other (specify)

Purpose:

Treatment

Financial

*Personal

*Other

I hereby authorize the following person or facility to release the above information to McLean Hospital:

I hereby authorize McLean Hospital to release the above information to the following person or facility:

To: Referring/Aftercare Clinician PCP Other

Name/Facility:

Address:

Date of Birth:

Specific information to be released:

Verbal Information/Telephone Update

Discharge/Treatment Summary

Other (specify)

Purpose:

Treatment

Financial

*Personal

*Other

I hereby authorize the following person or facility to release the above information to McLean Hospital:

I hereby authorize McLean Hospital to release the above information to the following person or facility:

To: Referring/Aftercare Clinician PCP Other

Name/Facility:

Address:

*Copying fees may apply

Information should be sent to: McLean Hospital, 115 Mill Street, Belmont, MA 02478-9106

Attention: (Name of McLean staff member who should receive the information)

Mental Health Information. I authorize disclosure of such information, including details of mental health diagnosis and/or treatment provided by a Psychiatrist, Psychologist, Licensed Mental Health Clinician, Advanced Practice Nurse, or Licensed Social Worker.

I understand that:

•I may withdraw my authorization at any time by submitting a written request to the Director of Health Information Management. Authorization may be withdrawn except to the extent that action has already been taken in reliance on this authorization. If the authorization was obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy, even if authorization has been withdrawn.

•I may refuse to sign this authorization. If I refuse to sign this authorization, my treatment, payment, health plan enrollment, or eligibility for benefits will not be affected.

•Information released on this authorization, if redisclosed by the recipient, is no longer protected by McLean Hospital.

• This release will expire 180 days from the date below or as otherwise specified:

 

.

YES Please check yes for the following questions, to indicate if we may release information below (if it is in your medical record.)

Alcohol and Drug Abuse Treatment. To the extent that my medical record contains information regarding alcohol or drug treatment that is protected by Federal Regulation 42 CFR, Part 2.

HIV Information. To the extent that my medical record contains information concerning HIV antibody and antigen testing that is protected by M.G.L. Ch.111 §70f.

Details of Domestic Violence Victims’ Counseling

Details of Sexual Assault Counseling

Patient or Patient Representative: Please make sure that all appropriate sections above are completed before signing this authorization. Do NOT sign a blank authorization form.

Signature of Patient (if 18 or older);

Printed Name of Patient or Authorized Person

Date

or Parent (if patient is under 18);

 

 

or Legal Guardian; or Health Care Agent (circle one)

 

 

Form 1668, revised 09/2016

White – Send to Medical Records Department

Yellow – File in current medical record

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Filling out this PDF typically requires attentiveness. Make certain each blank field is filled in correctly.

1. While filling out the Mclean Hospital Form 1668, make certain to include all necessary blanks within the associated area. It will help speed up the process, allowing for your information to be processed efficiently and accurately.

Step # 1 in submitting Mclean Hospital Form 1668

2. After completing the previous part, head on to the next part and fill out the necessary particulars in all these blank fields - Information should be sent to, Attention Name of McLean staff, Mental Health Information I, I understand that, cid I may withdraw my, cid I may refuse to sign this, for benefi ts will not be affected, cid Information released on this, YES Please check yes for the, Alcohol and Drug Abuse Treatment, treatment that is protected by, HIV Information To the extent, is protected by MGL Ch f, Details of Domestic Violence, and Details of Sexual Assault.

Simple tips to fill out Mclean Hospital Form 1668 part 2

3. Completing Patient or Patient Representative, Signature of Patient if or older, Printed Name of Patient or, Date, Form revised, and White Send to Medical Records is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Mclean Hospital Form 1668 writing process shown (part 3)

Always be extremely careful while completing Patient or Patient Representative and Form revised, as this is where a lot of people make mistakes.

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