Αποτελέσματα Αναζήτησης
IMPORTANT: If the PHI I am requesting contains information about drug/alcohol abuse, mental health treatment, genetic information, sexually transmitted diseases, HIV/AIDS testing or treatment or any other sensitive information, by signing this Patient’s Request to Access PHI form, I confirm that I am requesting access to this information, unless
Patient’s Request to Access Protected Health Information (“PHI”) I request my PHI from the following Mercy Facility: _________________________________________________________. Patient’s Name: ___________________________________________ Patient’s Date of Birth: ________________________.
Signature of Patient or Personal Representative: By signing this Authorization, I authorize disclosure of protected health information of above named patient by Provider as described above in this Authorization.
By signing this form, you authorize The Family Health Centers to release protected health information for the above-named patient according to the instructions below. If unable to reach the patient, we may (please check all that apply):
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form to obtain treatment unless the sole purpose for the treatment is the disclosure of information for which this authorization is necessary. Research participation requires a separate authorization by the patient.
Pittsburgh Mercy Health System Authorization for Use/Disclosure of Protected Health Information PMHS 101 Duplex form Page 1 of 2 Rev. February 19, 2021. IT IS IMPORTANT THAT YOU READ AND UNDERSTAND THE FOLLOWING INFORMATION THAT RELATES TO YOUR SIGNING THIS AUTHORIZATION TO USE/DISCLOSE.
