Nih 527 Form PDF Details

When navigating the complexities of obtaining medical records or authorizing their release to healthcare providers, the National Institutes of Health (NIH) 527 form plays a crucial role. This form is an essential tool used within the NIH Clinical Center for patients who wish to have their medical records released or to grant permission for their healthcare providers to access these records. Specifically designed to ensure patient privacy while facilitating the seamless sharing of vital medical information, the NIH 527 form requires comprehensive details to be filled out. This includes patient information, actions permitting or altering access to records by healthcare providers, and specifics about the type or extent of medical information to be released. Additionally, it outlines how to submit the form electronically, enhancing its accessibility for patients and their families. Notably, the form allows patients to authorize up to two outside care providers to obtain copies of their medical records permanently, which can be revoked at any time based on the patient's discretion. However, the form underscores the importance of completing every section thoroughly to avoid it being returned as invalid. It also highlights the need for specifying the purpose of the disclosure, whether for continued care, personal use, or another reason, ensuring that the release of information is tightly controlled and explicitly consented to by the patient.

QuestionAnswer
Form NameNih 527 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnih medical records, nih patient information, nih records, nih527

Form Preview Example

Phone #:
Fax #:

MEDICAL RECORD

Authorization for the Release of Medical Information

National Institutes of Health, Clinical Center

INSTRUCTIONS: This form must be completed in its entirety, each

Health Information Management Dept.

section must be completed or the form could be returned as

10 Center Drive, MSC 1192

invalid.

Building 10, Room B1L400

For more information or to submit this form electronically, please

Bethesda, MD 20892-1192

visit our website:

Phone: (888) 790-2133 or (301) 496-3331

https://clinicalcenter.nih.gov/participate/medicalrecordrequest.html

FAX: (301) 480-9982

*Please complete a separate form for each requestor*

 

1. PATIENT INFORMATION:

Patient Name:

Phone Number:

Date of Birth:

2.ACTION: Up to two outside care providers can have permanent authorization to obtain copies of medical records. This authorization may be revoked at any time upon your request. If the below named individual is not a healthcare provider, please skip this step.

Add New Care Provider - Please give the below named care provider access to my medical records.

Replace Authorized Care Provider - Replace existing care provider ___________with the below named care provider.

Remove Authorized Care Provider - Please remove the below named care provider’s access.

3.RELEASE INFORMATION TO: Who do you want to receive the requested records - Full Mailing Address Required.

Phone and fax are optional. All other fields are required

Name:

Address:

City:

State:

Zip Code:

Country:

4.INFORMATION TO BE RELEASED: Review options and check appropriate box(es):

DATES OF SERVICE TO BE RELEASED: From ______________ to _______________

☐Clinical Notes

☐Radiology Reports

☐Radiology Images (will be released on a CD)

☐Pathology Reports

☐Lab results

☐Other Diagnostic Test Results (Cardiac, Pulmonary Function, Neurological Testing, etc.)

☐Other (Please Specify) :

5.THE PURPOSE OR NEED FOR DISCLOSURE (Continued Care, Personal Use,etc):

6.AUTHORIZATION: Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above. Note: submission of this form authorizes future disclosures to the same individual and/or entity within one year from date of signature.

Patient/Authorized Signature

Print Name

Date

Patient Identification (Staff Use Only)

Authorization for the Release of Medical Information NIH-527 (7-21)

P.A. 09-25-0099

File in Section 4: Correspondence

How to Edit Nih 527 Form Online for Free

Having the objective of making it as easy to go with as it can be, we established our PDF editor. The procedure of completing the nih 527 sp is going to be very simple in the event you check out the next actions.

Step 1: Search for the button "Get Form Here" on the site and hit it.

Step 2: Once you enter the nih 527 sp editing page, you'll see each of the functions you can take about your document within the top menu.

These parts will frame the PDF document that you'll be creating:

part 1 to filling in nih 527 form

The application will need you to fill in the DATES OF SERVICE TO BE RELEASED, Clinical Notes Radiology Reports, Other Diagnostic Test Results, Neurological Testing etc Other, THE PURPOSE OR NEED FOR, AUTHORIZATION Permission is, PatientAuthorized Signature, Print Name, Date, Patient Identification Staff Use, and Authorization for the Release of segment.

step 2 to finishing nih 527 form

Step 3: Press the Done button to save your document. So now it is readily available for upload to your device.

Step 4: Make copies of your document - it can help you stay away from forthcoming troubles. And don't be concerned - we do not distribute or see your data.

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