Scott And White Doctors Note Form – Fill Out and Use This PDF

The Scott And White Doctors Note form is a critical document that authorizes Scott & White Healthcare to release medical information as per the patient's consent. This document is detailed, inclusive of specifying what types of information can be released, to whom, and for what purpose, whether it's for legal, personal use, continued care, or insurance purposes. Individuals looking to have their medical information released or shared should carefully fill out this form by clicking the button below.

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Scott And White Doctors Note Form PDF Details

In the realm of healthcare, the management and sharing of medical records are pivotal for continuous patient care, legal proceedings, insurance matters, and personal record-keeping. The Scott & White Doctors Note form, specifically designed for authorizing the release of medical information, plays a crucial role in this intricate process. By completing this form, a patient consents to Scott & White Healthcare to disclose specified parts of their medical records to designated individuals or organizations. This detailed form encompasses various sections that the patient must carefully consider, including the identification of the information to be released, the recipient's details, potential charges for photocopies as dictated by Texas law, and specific types of information that might require release, such as alcohol/drug use records, genetic information, HIV/AIDS status, and mental health details. Furthermore, patients have the option to select the purpose of the information release, whether for attorney/legal matters, continued care, insurance purposes, or personal use, highlighting the form's adaptability to diverse needs. The authorization is bound by a deep understanding of privacy laws and includes clauses about the right to revoke the authorization and the conditions under which the information may be redisclosed. Notably, the form also sets an expiration date for the authorization, offering patients control over their medical information. The Scott & White Doctors Note form exemplifies the balance between patient privacy rights and the necessity of sharing medical information for various legitimate reasons, all while emphasizing the patient's autonomy and understanding in navigating their healthcare journey.

Question	Answer
Form Name	Scott And White Doctors Note Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	baylor scott and white work excuse, er doctors note, doctors note, scott and white doctors note

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize Scott & White Healthcare to release the information indicated from the medical record of:

Patient Name	Date of Birth
Street Address	City, State Zip

Please release this information to:

Individual/Organization Name

Medical Record Number

Telephone Number

Street Address

City, State Zip

Fax Number

I understand there is a charge for photocopies, as permitted by Texas law, unless copies are sent directly to another

healthcare provider.□ I would like to review my record. Please release information from these hospitals or clinics: __________________________________________________

Please release the following information for these treatment dates: __________________________________________

Include this information (if applicable): □ Alcohol/Drug		□ Genetics	□ HIV/AIDS	□ Mental Health
Purpose: □ Attorney/Legal	Purpose: □ Continued Care	Purpose: □ Insurance		Purpose: □ Personal Use
□ Complete record	□ Summary information	□ Summary information		□ Complete record
□ Summary information	(clinic notes, history &	(clinic notes, history &		□ Summary information
(clinic notes, history &	physical, operative reports,	physical, operative reports,		(clinic notes, history &
physical, operative reports,	pathology reports,	pathology reports,		physical, operative reports,
pathology reports,	consultations, discharge	consultations, discharge		pathology reports,
consultations, discharge	summary)	summary)		consultations, discharge
summary)	□ EKG/EEG/EMG reports	□ EKG/EEG/EMG reports		summary)
□ EKG/EEG/EMG reports	□ Immunization records	□ Immunization records		□ Billing records
□ Immunization records	□ Laboratory reports	□ Laboratory reports		□ EKG/EEG/EMG reports
□ Laboratory reports	□ Radiology reports	□ Radiology reports		□ Immunization records
□ Medication records	□ Other: _______________	□ Other: _______________		□ Laboratory reports
□ Nursing notes	______________________	______________________		□ Medication records
□ Physician orders	______________________	______________________		□ Nursing notes
□ Progress notes	______________________	______________________		□ Physician orders
□ Radiology reports	______________________	______________________		□ Progress notes
□ Other: _______________	______________________	______________________		□ Radiology reports
______________________	______________________	______________________		□ Radiology images
______________________	______________________	______________________		□ Other: _______________

I understand the following:

I am not required to sign this authorization to obtain treatment at Scott & White.

If the recipient of this information is not a covered entity under federal or state privacy law, the information may be subject to redisclosure by the recipient.

I may revoke this authorization in writing at any time except to the extent Scott & White has already relied on this authorization. To revoke my authorization, I will provide a written request to the Health Information Management Department.

My record may contain information that only a physician can interpret. I will contact my physician if I have questions about my diagnosis or treatment. I will not hold Scott & White liable for any misinterpretation of information if I fail to contact my physician for clarification.

This authorization will expire in 180 days or at the date or event specified here: _________________________________

Signature of Patient or Legal Representative	Printed Name of Patient or Legal Representative

	Representative’s Authority to Act for Patient

MR FORM 4799

REVISED 1/12 (ITEM# 5428)

Date

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Date, MR Form Revised Item, and Signature of Patient or Legal in baylor scott and white work excuse

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Scott And White Doctors Note Form – Fill Out and Use This PDF

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