Memorial Hermann Release PDF Details

Memorial Hermann, a top healthcare system in Texas, has released a new form patients must sign before they can be admitted to the hospital. The new form, called the Memorial Hermann Release Form, gives the hospital permission to share the patient's medical information with certain third-party vendors. While some people are concerned about the privacy implications of this new form, Memorial Hermann maintains that it is necessary in order to provide patients with quality care. Patients who do not want their information shared with third-party vendors are free to refuse to sign the form.

Here is the details about the file you were in search of to fill out. It can show you the time you will require to complete memorial hermann release, exactly what parts you will have to fill in, etc.

QuestionAnswer
Form NameMemorial Hermann Release
Form Length1 pages
Fillable?Yes
Fillable fields64
Avg. time to fill out13 min 7 sec
Other namesmemorial hermann hospital discharge, 7737 swf c94, memorial hermann release of information, memorial hermann discharge papers

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)

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atf form p3317 2 blanks to consider

The application will require you to fill out the ENTIRE, RECORD, INCLUDING, HIV, TESTING, ONLY and EXCLUSION, S field.

Filling in atf form p3317 2 stage 2

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