Steps to Request Medical Records

SCOTTISH RITE

FOR CHILDREN

AUTHORIZATION TO DISCLOSE

HEALTH INFORMATION

MRN# (staff only):

S 159 Rev 5/2022, 6/2018

PATIENT NAME: DOB: PHONE NUMBER:

2222 Welborn St., Dallas, TX 75219

Ph: 214-559-7455 Fax: 214-559-7422

5700 Dallas Pkwy., Frisco, TX 75034

Ph: 469-857-2075 Fax: 469-857-2076

3800 Gaylord Pkwy., Ste. 850 Frisco, TX 75034

Ph: 469-857-2075 Fax: 469-857-2076

I hereby authorize SCOTTISH RITE FOR CHILDREN (SRC) to disclose treatment/medical information about the patient listed above

to:

PERSON / FACILITY NAME:

_____________________________

________________________________________________________________________________________________________________________________

STREET ADDRESS:______________________________________________________________________________________CITY:_________________________________________STATE:_________ZIP:___________

PHONE NUMBER:_____________________________________________________________________ FAX NUMBER:____________________________________________________________________

HECK

YPE

NFORMATION

UTHORIZED

ISCLOSED

NOTE--The appropriate box below must be checked to avoid delay of request. We will only disclose records specifically requested.

METHOD OF DELIVERY:  Pick-up  Mail  Fax

(Healthcare Organizations Only)

 MyChart  Verbal Communication



Email to: _____________________________________________



Encrypted



Unencrypted

(Information will be sent by encrypted unless I specify otherwise. By requesting unencrypted email, I acknowledge that there is some risk that health information could be accessed by a third party.)

ELECTRONIC MEDIA: CD USB/Flash Drive (flat rate)  PAPER COPY (rate dependent on # of pages)

DATE(S) OF SERVICE :_____________________________________________through__________________________________________________________

 Summary Abstract

(Clinic Progress Note, H&P, Operative Note, Lab,

Consult, Path, Radiology, Discharge Summary, Diagnoses/Procedure List)

 Facesheet – Includes Demographics

 Coding Summary (Diagnoses/Procedures) and Facesheet

 Progress Notes (Clinic, Inpatient or Outpatient)

 Center for Dyslexia Evaluation/Assessment Reports

 Care and Treatment –

VERBAL COMMUNICATION ONLY

 History & Physical

 Discharge Summary

 OP/Procedure Report

 Lab/Path Report

 Radiology Rep

ort

 Radiology Image - CD

 I

mplant Records

 Complete Medical Record

 Billing Record

 Peer Support (Parent Name/Phone #)

__________________________________________________

 Form/Letter/Other:

__________________________________________________

FOR THE PURPOSE OF: Personal Records School Military Legal  SSI/Disability Other _____________________

Continuity of Care; if applicable–Upcoming Appointment Date: _________________________________

YOUR INITIAL IS REQUIRED FOR THE FOLLOWNG SENSITIVE INFORMATION REQUESTS:



Genetic Info (including Genetic Test Results) Initial___________

 Mental Health (NOT Psychotherapy Notes) Initial____________



Drug, Alcohol, or Substance Abuse Records Initial____________

 AIDS/HIV Test Results and Treatment

Initial____________

I understand that:



This authorization will remain in effect for 1 year from the date signed. I further understand that I may revoke this authorization at any time by notifying our

main campus Health Information Management (HIM) Department in writing at 2222 Welborn Street, Dallas, Texas 75219.



Any Protected Health Information (PHI) released before a revocation or cancellation request – this has been released in good faith and is now in the records of a

healthcare entity or provider as previously authorized.



PHI used or disclosed pursuant to this form may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law; and

information received by SRC from another healthcare provider is subject to re-disclosure according to Chap 159, TX OCC 159.005(e) & HIPAA.



SRC is not responsible for any misuse or disclosure made by a third party to whom I have authorized release of the PHI.



I have the right to request or inspect or copy my PHI to be used or disclosed, as provided in CFR 164.524. I also understand that under HIPAA Privacy my access

to PHI may be restricted if appropriate for my care and treatment. If I have questions about disclosures of my PHI, I can contact HIM Dept. at SRC.



I can refuse to complete this authorization and if I do complete - I understand I do not have to provide a purpose for request of my PHI.



There may be nominal charges for copying and sending these records. This will be discussed at the time I sign or turn in this request.



Authorizing the disclosure of PHI is voluntary and that my (my child’s) healthcare treatment/eligibility for benefits will not be affected if I do not sign form.



The information in my (my child’s) health record may include information relating to sexually transmitted disease, acquired

immunodeficiency syndrome (AIDS),

or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, alcohol, or drug abuse, and/or social and

family related matters. Psychotherapy notes recorded by a mental health professional documenting or analyzing conversation during a counseling session are

maintained separately. Such information is subject to special protections pursuant to state and federal laws and regulations.

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________ _______________________________________________________________________________________

 ID Type (Staff Only):____________________

 Request Fulfilled: Date_________ Initials _____

Signature of Patient or Personal Representative Date

_______________________________________________________________________

Print Name of Patient or Personal Representative Relationship of Personal Representative’s Authority

 At the request of

the individual