Memorial Hermann Release PDF Details

Understanding the nuances of the Memorial Hermann Release form is essential for anyone in need of obtaining or understanding the flow of their medical records within the Memorial Hermann Health System. This comprehensive document serves as a bridge, allowing the distribution of a patient's health information across various facilities within the network upon the patient's authorization. With options for both inspection and amendment, the form empowers patients by giving them control over the disclosure of their Protected Health Information (PHI). From hospitals and outpatient centers alike, the form covers a wide range of facilities, including Memorial City, NW/Greater Heights, Southwest, and many others, providing a single mailing address for submission. It caters to various disclosure purposes such as medical care, legal matters, insurance inquiries, among others, and allows for the selection of the form in which the records are to be released, either paper or electronic. Importantly, it stipulates that the authorization is valid up to 180 days from the signature date, subject to certain conditions. Moreover, it outlines the rights of the patient to revoke this authorization at any time, highlighting the legal safeguards in place to ensure the patient's autonomy over their personal health information. This form underscores the balance between the need for information flow within healthcare systems and the protection of patient privacy, a cornerstone in the administration of modern healthcare services.

QuestionAnswer
Form NameMemorial Hermann Release
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmemorial hermann discharge papers, memorial hermann hospital discharge, memorial hermann release of protected health information, hermann medical release form

Form Preview Example

One mailing address for all facilities (not a physical address):

 

 

 

Memorial Hermann Release of Information

 

 

 

7737 SWF C94 Houston. TX 77074

 Inspection  Amendment Of Protected Health Information

Authorization for:  Disclosure

Patient Name

 

 

 

Date of Birth

Medical Records#

 

 

 

 

 

 

 

Address

 

 

 

 

 

Telephone #

 

 

 

 

 

 

(

)

I hereby authorize Memorial Hermann Health System to release my records from the following facilities

 

(please check ONLY facilities that apply):

 

 

 

 

 

 

HOSPITALS:

 

 

 

 

 

 

 

 Memorial City

 NW/Greater Heights

 Southwest

 Northeast

 

 Sugar Land

Hermann-TMC

 Katy

 

 Woodlands

 Southeast

 

 TIRR

 MHOSH

 Cypress

 

 Pearland

 Katy Rehab

 

OUTPATIENT CENTERS:

 

 

 

 

 

 

 River Oaks

 Outpatient Imaging Center

 Sport Medicine/Physical Therapy

 Medical Group

 

 Katy

 Convenient Care Center

 

 PhyTex/Mischer Assoc.

 Home Health

 Physicians at Sugar Creek

RELEASE TO: Please provide Name/Address of person/organization to which disclosure is to be made

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Phone # ___________________________________________________ Fax# _______________________________________________________

DATES OF SERVICE to be released: _________________________________________________________________________________________

 

 

Specify dates - this line MUST BE completed

For the following purpose: Medical Care

Legal

Insurance

Other (detail below)

__________________________________________________________________________________________________________________________

COPY MY MEDICAL RECORDS TO: please check one  PAPER OR  Electronic Disclosure such as CD

Select Portions of Protected Health Information MHHS is authorized to release

Abstract/Pertinent Information

 

Lab

ENTIRE RECORD INCLUDING - HIV TESTING ONLY

Emergency Room

 

Radiology Reports

EXCLUSIONS

Admit/Discharge Summary

_____________________________________________________________

MD Progress Notes

H&P

_____________________________________________________________

Cardiac Studies

Radiology Digital Images

Consultation Report

Itemized Bill

Face Sheet

CPT Codes

Operative/Procedure Report

Other _______________________________________________________

This authorization is valid until the 180th day after the date it is signed unless it provides otherwise, not to exceed 24 months, or

unless it is revoked, and covers only treatment(s) for the dates specified above.

I, the undersigned, have read the above and authorize the staff of Memorial Hermann Health System to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extend that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my Protected Health In formation.

______________________

___________________________________________________________

____________________________________

Date

Signature of Patient/Parent/Conservator/Guardian

Authority/Relationship to Patients

Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information. Records will be released after full payment has been received.

Release of Protected

Health Information

73115 (10/17)

How to Edit Memorial Hermann Release Online for Free

We chose the top-rated web programmers to design our PDF editor. This app will help you create the hermann information form file easily and won't eat up too much of your time and effort. This convenient procedure can help you get started.

Step 1: At first, choose the orange "Get form now" button.

Step 2: So, you may alter your hermann information form. Our multifunctional toolbar allows you to include, remove, transform, highlight, and also carry out several other commands to the content and fields inside the file.

Type in the requested data in each one section to get the PDF hermann information form

hermann medical release form blanks to consider

The application will require you to fill out the For the following purpose Medical, Select Portions of Protected, AbstractPertinent Information, ENTIRE RECORD INCLUDING HIV, EXCLUSIONS, Radiology Digital Images, This authorization is valid until, Date Signature of, and Feescharges will comply with all field.

Filling in hermann medical release form stage 2

Step 3: Hit the Done button to be sure that your finished file can be transferred to each electronic device you choose or sent to an email you specify.

Step 4: Get minimally several copies of your file to prevent any specific possible difficulties.

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