..

HealthAllianceHospital

A Member of UMass Memorial Health Care
60 Hospital Road
Leominster, MA01453-8004 / *RL0004* /

MR#:______

RL0004 / Correspondence

Authorization for the Disclosure of Personal Health Information

I hereby authorize HealthAllianceHospitals, their employees, and/or agents, to release information from the medical record of:
Patient Name: First: MI: Last: Sex: M F
Please Print Suffix: (Sr. Jr. I, II, etc) Check one::
Street: Floor/Apt#:
City: State: Zip Code:
Phone #: Date of Birth:
Please Release To: /  / Self /  / Physician ( no charge if sent directly to
physician’s office by HIS) /  / Organization
(Ins. Co., Lawyer, etc.)
Name:
Street: PO Box/Suite #:
City: State: Zip Code:
Phone #: Fax #:
I understand that my health record may include information related to my mental health, drug/alcohol abuse, sexual assault, sexually transmitted diseases, abortion, genetic testing, HIV/AIDS, domestic violence, or other information I may consider sensitive. If there are exclusions, I have indicated them in writing below:
Listed Exclusions (if any):
Note: Charges for copies are based upon a per page charge and if applicable, a processing fee and postage.
REQUEST TYPE: I request copies of the following records:
Itemized Hospital Bills / Date(s) of Service:
Laboratory/Pathology Reports Only / Date(s) of Service:
Radiology Reports Only / Date(s) of Service:
Outpatient Clinics / Audiology, Cardiac Rehab, Diabetes, Oncology, PT/OT/ST Physiatry, Take Charge, etc. / Date(s) of Service:
Type of Clinic(s):
Definitions of content released when requesting the following visit/encounter types listed below:
Abstract: Includes Diagnostic Tests (Labs, Rads, Echos, PFT, etc.) Problem List, Medication Reconciliation List, Allergies and all Dictated Reports)
An “Abstract” is less expensive than requesting the entire encounter/visit and includes most all pertinent information.
Entire Encounter/Visit: Includes all documentation within a specific encounter/visit date.
Emergency or Urgent Care /  Abstract /  Entire Encounter/Visit / Date(s) of Service:
Same Day Surgery /  Abstract /  Entire Encounter/Visit / Date(s) of Service:
 Hospital Stay (Inpatient or Observation) /  Abstract /  Entire Encounter/Visit / Date(s) of Service:
Definition of content released when requesting an entire medical record below:
Entire Medical Record Includes any and all documentation related to all encounters/visits within the last 20 years.
Medical Record / Abstract / Entire Medical Record- HIS Staff Confirm / SpecificDateRange:
Please Continue On Reverse Side
Patient Name: First: ______MI: ______Last:______
I understand the following:
  • This authorization is voluntary.
  • Per the Notice of Information, I have the right to inspect or request copies of my medical records. Arrangements must be made to inspect my medical record on-site; please contact the Health Information Services Department at978-466-2834.
  • A fee for copies of my medical record may apply; per Massachusetts General Law; Chapter 111, Section 70.
  • Any disclosure carries the potential for unauthorized re-disclosure. I release HealthAlliance from any legal liability that may arise from the disclosure or re-disclosure of this information.
  • I have the right to revoke the authorization at any time by presenting a written request to the Health Information Services Department (Medical Records) at the address below. Revocation will not apply to information that has already been released in response to this authorization. Revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
Expiration of Authorization: Unless otherwise revoked in writing, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization shall be valid for not more than ninety (90) days from the date of the signature below, except when Federal and/or State regulations specify otherwise.
The Reason for Request is: (check one)
Continuing Medical TX /  Self- Personal Use / Attorney/Legal /  School
Insurance Company /  Disability (Requires documentation) / Pre-Employment /  Other:______
Requested Format for Receipt of Medical Records
Copies generally available within 20 business days dependent upon type of request selected
Paper Copies
Records will be MAILED with the invoice from HealthPort, our release of information partner, unless otherwise requested:
Please send an invoice
before mailing the records. / E-Mailed * via HealthPort’s secure connection.
*Please read and complete the “eDelivery Request Letter” and the “E-Delivery Take Away Letter”. Both forms are available on our website: or from the Medical Records (HIS) Department .
Billable Requests Only / Electronic – CD Format
PICK UP ONLY in Medical Records Department on the 2nd floor of the hospital. You will be invoiced separately from HealthPort, our release of information partner.
 Self Other * (indicate below)
HIS Staff–OBV or Inpt request? If so, complete worksheet and process ASAP
A Picture ID is Required When Picking Up Electronic Copies of Medical Records
*If someone other than the patient will pick up the electronic copies of you medical record, please provide their name and relationship below:
Name:______Relationship to Patient:______
I have completed all sections of this form. I have read and understand the above statements and authorize the disclosure of the information requested on the reverse side of this form.
______
Signature of Patient / Parent / Legal Guardian / ______
Date / ______
Relationship to Patient
Please mail or fax your request to: / HealthAllianceHospital
Health Information Services Department
Attn: Correspondence
60 Hospital Road
Leominster, MA01453
Phone (978) 466-2834 Fax (978) 466-2789
Original - Medical Record
Form # NS 1110 Revision Date: 04-01-2011 / Chart Tab Placement: Legal Documentation