Memorial Hermann Release – Fill Out and Use This PDF

Memorial Hermann Release is a mobile app that helps patients release their medical records.

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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.

Question	Answer
Form Name	Memorial Hermann Release
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	memorial hermann discharge papers, memorial hermann hospital discharge, memorial hermann release of protected health information, hermann medical release form

12

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		 Inspection  Amendment Of Protected Health Information
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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