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When it comes to managing healthcare information, the Memorial Hermann Release form plays a pivotal role for patients within the Memorial Hermann Health System. This form ensures that individuals have the ability to authorize the disclosure of their protected health information to specified parties for designated purposes. With a single mailing address serving all facilities, the process is streamlined for patients to request information release. Whether for medical care, legal issues, insurance needs, or other purposes, the form accommodates a wide range of requests, including inspections and amendments of health records. Patients have the option to select specific hospitals and outpatient centers from which records should be released, and can specify the type of media—paper or electronic—preferred for the copies of their medical records. Detailed options are provided to allow individuals to clearly designate which portions of their health information can be disclosed, from abstracts and lab results to comprehensive records, including sensitive HIV testing. Additionally, the form outlines the validity of the authorization, emphasizes the right of the signer to revoke consent at any time, and educates on the potential for re-disclosure by the recipient. Importantly, it also includes a provision detailing the protection from liability for the releasing facility once lawful disclosure of the requested information is completed. This crucial document ensures that the legal requisites for sharing medical information are respected, while offering clarity and control to the patient over their own health information.

Document 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

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)

⇩ Memorial Hermann Release File

Form Attributes

Fact Name Detail
Mailing Address The form specifies one mailing address for all facilities: Memorial Hermann Release of Information 7737 SWF C94 Houston, TX 77074.
Purpose of Authorization Authorization can be for inspection, amendment, or disclosure of protected health information.
Specific Facilities Patients must specify from which Memorial Hermann Health System facilities their records are to be released, including hospitals and outpatient centers listed.
Recipient of Information The form requires the name and address of the person or organization to whom the disclosure is to be made.
Type of Disclosure Patients can choose to have their medical records copied to paper or electronic format such as a CD.
Portions of Protected Health Information Patients can select specific portions of their health information to be released, including but not limited to emergency room reports, radiology reports, and entire record including HIV testing only.
Authorization Validity This authorization is valid until the 180th day after being signed, not to exceed 24 months, unless revoked earlier.
Revocation and Re-disclosure Patients have the right to revoke this authorization in writing at any time, but it may not affect actions already taken. Information disclosed may be subject to re-disclosure and might not be protected.
Liability Release Signing the form releases and holds harmless the facility and its parent company from liability for the lawful release of protected health information.
Compliance with Laws Fees and charges for the release of information will comply with all applicable laws and regulations.

How to Fill Out Memorial Hermann Release

After you have received the Memorial Hermann Release form, it's essential to fill it out carefully to ensure your medical records are handled according to your wishes. This form is pivotal for authorizing the Memorial Hermann Health System to disclose your health information to designated parties for purposes such as medical care, legal matters, insurance claims, or other specified reasons. Here's a step-by-step guide to help you complete the form accurately.

  1. Start by entering your full name as the patient along with your date of birth and medical records number in the designated fields at the top of the form.
  2. Write your current address and telephone number in the corresponding sections to ensure the Health System can contact you if needed.
  3. From the listed facilities, check only those from which you want your records released. Be selective to limit disclosure to relevant entries.
  4. Provide the name and full address of the person or organization to whom the disclosure is to be made under "RELEASE TO." Don’t forget to include their phone and fax numbers for any necessary follow-up.
  5. In the "DATES OF SERVICE to be released" section, specify the exact dates of service for which your records are needed, ensuring clarity and avoiding unnecessary release of information.
  6. Select the purpose of the release by checking the appropriate box—Medical Care, Legal, Insurance, or Other. If you select "Other," provide a detailed explanation.
  7. Choose the format in which you wish your medical records to be copied, either PAPER or Electronic Disclosure such as CD, by checking the relevant box.
  8. Identify the parts of your Protected Health Information to be released by checking the specific types of records needed, such as Lab reports, ENTIRE RECORD INCLUDING - HIV TESTING ONLY, Emergency Room summaries, etc. Include any exceptions or exclusions if necessary.
  9. Sign and date the form at the bottom to authorize the release. If you are not the patient but have the authority to request the release, state your relationship to the patient next to your signature. Ensure the date is correct to avoid any processing delays.

It's important to remember that this form has a validity period: it expires 180 days after signing unless a different expiration date is specified, but it cannot exceed 24 months. Keep in mind, too, that you have the right to revoke this authorization at any time, unless action has already been taken based on your initial request. Once completed, ensure you review your form for accuracy before submitting it to the Memorial Hermann Release of Information office. This step is crucial for making sure your health information is handled securely and in accordance with your directions.

Common Questions

What is the Memorial Hermann Release Form?

The Memorial Hermann Release Form is a document that allows Memorial Hermann Health System to share your protected health information (PHI) with the person or organization specified in the form. This might include releasing your medical records to other healthcare providers, legal representatives, insurance companies, or for other purposes you designate.

How can I specify which facilities my records should be released from?

In the form, you are provided with a list of Memorial Hermann hospitals and outpatient centers. Check only the facilities from which you want records released. These facilities include hospitals spread across various locations, rehabilitation centers, outpatient imaging centers, and more.

Who can I release my medical records to?

You can authorize the release of your medical records to any person or organization. This includes, but is not limited to, another healthcare provider, a lawyer, an insurance company, or yourself. Please provide the complete name and address of the recipient in the designated section of the form.

What sections of my medical record can be released?

You have the option to specify which parts of your medical record you want to be released. Choices range from a comprehensive release of all records, including sensitive information like HIV testing, to specific sections such as laboratory results, radiology reports, emergency room records, and more.

Can I request the records in a specific format?

Yes, you have the option to receive your medical records in paper form or as an electronic disclosure, such as a CD. Please indicate your preference on the form.

Is there a validity period for this authorization?

This authorization is valid for 180 days from the date it is signed, unless specified otherwise, and cannot exceed 24 months. You can revoke this authorization at any time in writing, except where action has already been taken based on your authorization.

What happens if the information is re-disclosed?

Once your protected health information is released according to your authorization, it may be subject to re-disclosure by the recipient. This means that the information may no longer be protected under the privacy rules that originally applied to it within Memorial Hermann Health System.

Is there a fee associated with the release of records?

Fees for the release of medical records comply with all applicable laws and regulations. Records will be released after full payment of any associated fees has been received.

How can I revoke this authorization?

You can revoke this authorization at any time by submitting a written notice. However, revocation is not effective if Memorial Hermann Health System has already acted based on your initial authorization.

What is the significance of the release date and signature section?

The date and signature section at the bottom of the form is vital as it confirms your agreement to the release of your protected health information as specified in the document. It requires the date of the signature, your signature, and your relationship to the patient if you are not the patient signing the form.

Common mistakes

When filling out the Memorial Hermann Release form, individuals often make several mistakes that can lead to delays or incorrect processing of their request. Paying close attention to detail and understanding the requirements can make the process smoother and ensure accurate handling of one's medical records.

  1. Not specifying the dates of service to be released is a common error. The form clearly states that the line for dates of service "MUST BE completed." Failing to specify these dates can result in incomplete information retrieval or the processing of your request being delayed.

  2. Another mistake is overlooking the need to choose between paper and electronic disclosure formats. This choice impacts how you will receive your medical records. Not making a selection could lead to confusion regarding the preferred method of receiving the information.

  3. Individuals often neglect to check the appropriate boxes under the "Choose Portions of Protected Health Information MHHS is authorized to release" section. This oversight can result in either too much or too little information being released, depending on what was actually needed for the intended purpose.

  4. Failing to properly identify the recipient of the disclosed information is a critical mistake. The form requires the name and address of the person or organization to whom the disclosure is made to be clearly written. Incomplete or inaccurate recipient information can prevent the records from being correctly sent or released.

In order to avoid these mistakes, it's essential to review the entire form carefully before submission, ensuring that all necessary sections are completed accurately and thoroughly. Pay special attention to the areas highlighted above, as these are common points of confusion or error.

Documents used along the form

When working with Memorial Hermann Health System on matters involving the release of protected health information (PHI), several forms and documents might accompany the Memorial Hermann Release form. It's crucial to understand what each of these documents signifies to ensure informed consent and compliance with protocols for the dissemination of PHI.

  • HIPAA Authorization Form: This form is pivotal in securing the patient's consent to disclose health information in alignment with the Health Insurance Portability and Accountability Act (HIPAA) standards. It specifically outlines the types of health information that can be disclosed, the purposes for disclosure, and to whom the information can be released.
  • Advance Directives: While not always directly related to the release of information, advance directives can accompany these requests, especially in situations involving critical care or end-of-life decisions. They are documents that specify a patient's wishes regarding medical treatment in scenarios where they can no longer communicate their preferences.
  • Power of Attorney for Healthcare: This legal document designates an individual to make healthcare decisions on behalf of the patient if they become incapable of making those decisions themselves. It often accompanies the release form when the patient is unable to give consent due to their medical condition.
  • Request for Amendment of Health Information: If a patient believes that their medical records are incorrect or incomplete, they can submit this document requesting amendments to their PHI. Although this form focuses on corrections rather than release, it's closely associated with ensuring the accurate processing and handling of health information.

Understanding these documents ensures a comprehensive approach to managing and sharing protected health information. Whether it's ensuring compliance through a HIPAA Authorization Form, appreciating the patient's healthcare wishes via Advance Directives, designating decision-making through a Power of Attorney for Healthcare, or maintaining accuracy with a Request for Amendment of Health Information, these documents each play a vital role in the careful and respectful handling of health information. Familiarity with these forms can significantly enhance the efficiency and sensitivity with which health information is treated, thereby upholding the patient's rights and the integrity of the healthcare system.

Similar forms

The HIPAA Authorization Form is notably similar to the Memorial Hermann Release form, as they both facilitate the release of protected health information (PHI). Both documents require the specific identification of the patient whose information is to be disclosed and detail the purpose for which the information is needed. These forms mandate a signature from the patient or their legal representative, granting permission for healthcare providers to disclose PHI to third parties specified in the document. The importance of maintaining confidentiality and the patient's right to revoke the authorization are key elements shared by both forms.

A Medical Records Release Form shares its core function with the Memorial Hannermann Release form in allowing healthcare facilities to distribute a patient's medical information. This form typically asks for the patient's identification details, the specifics of the information to be released, and the receiving entity's details, very much like the Memorial Hermann Release form does. The main goal is to ensure that a patient’s medical history can be shared for reasons ranging from continuing care to legal purposes, with explicit consent from the patient.

An Advance Directive Form, while primarily designed to outline a patient’s preferences for medical treatment and end-of-life care, also contains aspects of information sharing similar to those in the Memorial Hermann Release form. It might specify circumstances under which patient information can be shared with healthcare providers and family members. Although its primary purpose differs, the consideration of patient consent and the potential need to share sensitive information paralleled in both forms highlight patient autonomy and privacy.

The Notice of Privacy Practices is another document that, while broader in scope, overlaps with the Memorial Hermann Release form in its concerns with PHI. This notice informs patients about how their health information may be used and disclosed by the healthcare provider and outlines the patients' rights regarding their information. The underlying principles of patient information protection and the conditions under which information can be disclosed without explicit consent align with the privacy considerations in the Memorial Hermann Release form.

An Authorization for Use of Image and Voice in Media is a document that, like the Memorial Hermann Release form, deals with consent for releasing personal information. Instead of health records, it pertains to the use of a person's likeness and voice. Both documents require clear, informed consent from the individual or their representative, indicating how and to whom the personal information can be disclosed. They share the common ground of protecting individuals’ rights over their personal information and setting clear boundaries for its release.

The Patient Consent for Research Form resembles the Memorial Hermann Release form in that it involves the sharing of personal health information, but in this case, for research purposes. Participants must consent to their health information being used, specifying which parts of their medical records can be disclosed to researchers. The emphasis on informed consent, the detailed outlining of information to be shared, and protection of participant privacy echo the safeguards present in the Memorial Hermann Release form.

Lastly, the Power of Attorney for Healthcare Form, while mainly authorizing another individual to make healthcare decisions on behalf of the patient, can entail the access and disclosure of the patient's PHI in order to make informed decisions. This document shares the concept of designated authority found in the Memorial Hermann Release form, as both necessitate clear authorization from the patient for others to access or disclose their personal health information. The focus on ensuring that the patient’s wishes are respected, whether in treatment or information disclosure, unites these documents.

Dos and Don'ts

When filling out the Memorial Hermann Release form, adhering to certain do’s and don’ts will ensure the process is completed efficiently and correctly. Below are important guidelines to follow:

  • Do ensure that you have the correct form version by verifying the date and form number, which is Release of Protected Health Information 73115 (10/17).
  • Do clearly print the patient's name, date of birth, medical record number, address, and telephone number to avoid any confusion or misinterpretation of information.
  • Do check the applicable box for the type of authorization you are requesting, whether it's for disclosure, inspection, or amendment of protected health information.
  • Do accurately select ONLY the facilities from which you are authorizing the release of medical records by checking the appropriate boxes provided.
  • Do specify the individual or organization's name and address to which the disclosure is to be made, ensuring clarity and accuracy in the information provided.
  • Don’t leave the “DATES OF SERVICE to be released” section incomplete. Specifying dates is mandatory for processing your request.
  • Don’t forget to check whether you request your medical records in paper or electronic form.
  • Don’t neglect to sign and date the form. Your signature confirms your authorization for the release and acknowledges your understanding of its content.
  • Don’t omit providing the authority/relationship to the patient if you are not the patient yourself but are authorized to act on their behalf.
  • Don’t disregard the mention that fees/charges will comply with all laws and regulations applicable to the release of Protected Health Information and that records will be released after full payment has been received.

Following these guidelines will ensure your request is processed in a timely and legally compliant manner, securing the necessary medical information without unnecessary delay or confusion.

Misconceptions

Misconceptions about the Memorial Hermann Release form can lead to confusion or mishandling of your medical records request. It's essential to understand exactly what the form entails to ensure your healthcare information is managed correctly.

  • All facilities require separate forms: A common misunderstanding is that a new form is needed for each Memorial Hermann facility from which records are being requested. In truth, one form serves to request records from any of the listed facilities, provided they are checked accordingly on the form.
  • Electronic records are not available: Many believe their medical records can only be provided in paper format. However, the form clearly allows for records to be requested in an electronic format, such as a CD, offering more convenience and quicker access to the patient or the authorized recipient.
  • Authorization lasts indefinitely: Some might think once signed, the authorization for the release of their records has no expiration. Actually, the authorization is valid until the 180th day after it is signed, not exceeding 24 months, unless it specifies otherwise or is revoked by the patient.
  • Amendments to records are not possible: Another misconception is that this form is purely for the disclosure or inspection of records and does not cater to amendments. However, the form does provide an option to request amendments to your Protected Health Information, ensuring accuracy and completeness of your medical record.
  • Any information disclosed is permanently protected: While the form allows for the sharing of information with specified parties, it's crucial to realize that once this information is disclosed, it might be subject to re-disclosure by the recipient and may not remain protected under this authorization. This detail underscores the importance of carefully choosing the information to be released and to whom.

Understanding these nuances ensures that individuals are better informed about their rights and the processes related to the handling of their medical records, leading to more effective and secure management of their personal health information.

Key takeaways

When you're filling out and using the Memorial Hermann Release form, it's crucial to pay attention to some key details to ensure that the process is completed correctly. Here's a rundown of the most important aspects:

  • Accurate Information: Start by making sure all the information you input is correct. This includes the patient's name, date of birth, medical record number, and contact details.
  • Specifying Facilities: The form allows you to select which Memorial Hermann facilities you're authorizing to release your information. Only check the boxes next to the facilities that apply to avoid any unnecessary sharing of your health information.
  • Release Recipient Details: Clearly provide the name and address of the person or organization to whom the disclosure is being made. It's essential for ensuring that your records are sent to the right place.
  • Dates of Service: You must specify the dates of service for which you're requesting records. This helps in pinpointing exactly which records need to be released.
  • Type of Disclosure: Indicate whether you prefer your medical records to be provided in paper or electronic form. Additionally, specify which portions of your health information you authorize to be released, such as lab reports or the entire record.
  • Revocation and Authorization Validity: Understand that this authorization is valid until the 180th day after it's signed, not to exceed 24 months, unless revoked earlier by you. It covers only the treatments for the dates specified on the form. You have the right to revoke this authorization at any time in writing, but it won't affect any actions taken based on the authorization before your revocation.

Always review the completed form to ensure everything is accurate and fully understood. If there's anything you're uncertain about, don't hesitate to ask for clarification. Keeping these key points in mind will help make the process smoother and protect your privacy and health information.

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