Vanderbilt Form Mc 3916 PDF Details

Are you a new student at Vanderbilt University? If so, you will need to complete the Vanderbilt Form Mc 3916. This form is used to collect important information about you and your family. The information that you provide on this form will help us to provide you with the best possible educational experience. Completing this form is mandatory, so be sure to take your time and fill it out accurately. Failure to complete this form may result in delays in your enrollment process or other unwelcome consequences.

Here's some facts that will help you learn how long it can take to finish the vanderbilt form mc 3916.

QuestionAnswer
Form NameVanderbilt Form Mc 3916
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesvanderbilt university medical center medical records, vanderbilt medical records fax number, vanderbilt hospital medical records, vanderbilt medical records

Form Preview Example

Authorization for Release of Medical Information

Vanderbilt University Medical Center

Medical Information Services ∙ 4560 Trousdale Drive, Suite 101, Nashville, TN 37204

Vanderbilt University Medical Center contracts with HealthPort to process requests for copies of medical records. The release of patient medical information is governed under federal and state laws.

To release your medical information from Vanderbilt University Medical Center, you must:

∙Complete all sections of the Authorization for Release of Medical Information form.

∙Hand-deliver, mail, or fax a signed request in writing to VUMC, Attn: Release of Information.

∙If you are under the age of 18, your parent or legal guardian must sign as well.

What we will provide to the patient at no cost (For patient Walk-in requests only).

At no cost to you, we will provide up to 50 pages of the medical records that are relevant to your care. This is called an abstract. If you want additional records, you will need to specify which ones on page 3.

What is an abstract?

An abstract contains only the medical records needed by you and your providers to continue your care after discharge. This is what is released unless you ask for your legal medical record. (The abstract usually includes: Discharge Summary, History & Physical, Lab, Pathology, Operative Reports, Procedure Notes, Radiology Reports, Problem List and Medications).

What is a legal medical record?

In addition to what is in the abstract, your legal medical record has all the information needed to identify you, support your diagnosis, justify your treatment, and document your care and results.

What we will provide for a reasonable fee

If you want your records sent to someone other than your doctor or for your own personal use, you must complete and sign an authorization. Also, you or the person receiving the records must agree to pay the fees. Here are the fees, based on Tennessee Code Annotated 68-11-304(a)(2):

$0.85 per page for 1 to 50 page.

$0.35 per page for over 250 pages

$0.60 per page for 51 to 250 pages

$0.50 per electronic photograph

Plus postage and any taxes that may apply

 

If you would like to know in advance if the fee will be more than a certain amount, indicate this here: Let me know if the fee for my records will be more than $____________.

I understand that there may be fees for copying my medical records. By signing below, I agree to pay these fees when I am billed for them by HealthPort.

Name: ________________________________________________ Phone: ( ____ ) _______________

 

Address: ___________________________________________________________________________

 

Street

City

State

Zip

Signature: _____________________________________________ Date: _______________________

Page 1 of 4

MC 3916 (Rev. 07/2012)

Authorization for Release of Medical Information

Please contact the following departments directly, if your request for information is related to home care services, radiology/imaging services, pharmacy services, or financial records.

HOME CARE SERVICES:

RADIOLOGY IMAGES (X-Rays):

2120 Belcourt Avenue

Radiology Film Library

Nashville, TN 37212

1211 22nd Avenue South

(615) 936-0336

1098 VUH

 

Nashville, TN 37232-2675

 

(615) 322-6311

PHARMACY (Outpatient):

FINANCIAL OR BILLING RECORDS:

1301 22nd Ave. S.

Patient Accounting

Nashville, TN 37232-5611

One Hundred Oaks

(615) 322-6480

719 Thompson Lane, Ste 30140

 

Nashville, TN 37204

 

(615) 936-0910 or (866) 488-4677

How to Take Back (Revoke) your Authorization for Release of Medical Information

You have the right to take back (revoke) your authorization to release of your medical records. To do this you must put your request in writing and mail it to:

Vanderbilt University Medical Center

Medical Information Services

Attn: Release of Information

4560 Trousdale Drive

Suite 101

Nashville, TN 37204-4538

If you have any questions please call the Release of Information Department at 615-322-2062.

Revoking this authorization will not affect any actions that Vanderbilt University Medical Center may have already taken based on the authorization.

Also, if the authorization was a condition for getting insurance, revoking it does not affect the insurer’s right to contest a claim made under the policy, or the policy itself.

When you release your medical information, whoever receives it may share it (except for any notes about drug or alcohol use and psychotherapy notes) with someone else. In this case, the information may no longer be protected by the HIPAA/Privacy Rule.

Treatment cannot be withheld or based on getting this authorization.

Page 2 of 4

MC 3916 (Rev. 07/2012)

Medical Record #__________________

FOR STAFF USE ONLY

Authorization for Release of Medical Information

Please complete all pages of this form, sign, and return to:

Vanderbilt University Medical Center ∙ Medical Information Services ∙ Attn: Release of Information ∙ 4560 Trousdale Drive ∙ Suite 101 ∙

Nashville, TN 37204-4538. Or submit by fax to (615) 343-0126. Contact our office at (615) 322-2062 with questions.

Vanderbilt Psychiatric Hospital ∙ Medical Information Services ∙ Attn: Release of Information ∙ 1601 23rd Ave. South

Nashville, TN 37212. Or submit by fax to (615) 327-7158. Contact our office at (615) 327-7153 with questions.

PATIENT

IDENTIFICATION

Name:

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

State:

Zip:

 

 

 

 

 

 

 

 

 

Previous Name:

 

Social Security#:

 

 

 

 

 

 

 

 

 

 

 

Patient Phone#:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I request and authorize Vanderbilt University Medical Center to release medical information of the

patient named above.

RELEASE RECORDS TO: (Where records should be sent)

Mail

Pick up in person Fax Electronic

Same as above

Name/Agency:

Address:

City:

 

 

 

State:

 

Zip:

 

Phone#:

 

Fax#:

 

 

 

 

 

E-mail Address:

 

 

(For Doctors or other HealthCare Providers Only)

INFORMATION REQUESTED: Fees may apply. See fee schedule on page 1.

Is this request for psychotherapy notes? separate authorization for any items below.

If yes, this is the only item you may request on this authorization. You must submit a If no, you may check any items below.

MEDICAL RECORD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCLUDES

 

 

 

 

 

DATES OF TREATMENT TO BE RELEASED

 

 

 

 

 

RECORDS FROM:

 

Dates from :

 

 

 

to

 

 

 

 

Or specific date:

 

 

 

 

 

 

 

 

 

 

∙ Vanderbilt

 

Abstract (see definition on page 1)

 

 

 

 

 

 

 

 

 

 

 

University Hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal medical record (see definition on page 1)

 

 

 

 

 

 

 

 

 

 

 

∙ Monroe Carell Jr.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OR Specific Categories

 

 

 

 

 

 

 

 

Children’s Hospital at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vanderbilt

 

History and physical

 

Radiology reports

Obstetrics (labor and delivery)

 

∙ Vanderbilt

 

Discharge summaries

 

Cardiac reports

Office/clinic notes

 

 

 

 

 

Psychiatric Hospital

 

Operative/procedure notes

 

Pathology reports

Respiratory reports

 

∙ Vanderbilt Medical

 

Consultations

 

Lab results

Circle One:

 

 

 

 

 

Group

 

 

 

 

 

Emergency services

FMLA, Power of Attorney,

 

 

 

Other (specify):

 

 

 

 

 

Pre-Admission Screening & Resident Review)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

The information to be released will cover the time period from:

 

to

 

Specific Date:

 

 

 

 

 

 

 

– specify):

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Payment Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 4

 

 

 

 

 

 

MC 3916 (Rev. 07/2012)

 

PURPOSE OF

RELEASE

h other health care provider as needed

(i.e., FMLA)

Other (specify):

Authorization for Release of Medical Information

I understand that my medical record may include information on diagnosis or treatment related to psychiatric or psychological conditions, drug or alcohol abuse, and acquired immune deficiency syndrome (AIDS) or HIV status. I agree that any information about such diagnosis or treatment may be released.

I also understand that if I do not ask for my legal medical record or specify the records I want, the Medical Information Services department will send an abstract of my legal medical record.

PLEASE INITIAL THE STATEMENT BELOW THAT APPLIES

(You must initial one): I do ________ do not ________ authorize this information to be released.

I would like to limit the information to:

I understand that:

∙I may refuse to sign this authorization.

∙Refusing to sign this authorization will not affect my treatment, payment, enrollment, or eligibility for benefits.

∙I may take back (revoke) this authorization in writing, except for any actions already taken based upon it.

∙I understand that this authorization will expire when the records are released for the request dated below. Any requests after this date will need a separate authorization.

∙If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy rules and may be shared with others.

∙I get a copy of this form after I sign it.

Signature of Patient/Legal Representative:

 

Date:

 

 

 

Relationship to Patient:

Page 4 of 4

MC 3916 (Rev. 07/2012)

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