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How to use or fill out valleyhealthsystemlv sitesvalleyhealthSummerlin Hospital Authorization to Use and Disclose with our platform
- Click ‘Get Form’ to open the valleyhealthsystemlv sitesvalleyhealthSummerlin Hospital Authorization to Use and Disclose in the editor.
- Initial the first box if you are requesting records from Summerlin Hospital. If you want records sent from another facility, initial the second box. For viewing original medical records, initial the third box.
- Fill in your Patient Name at Time of Treatment, Date of Birth, and Social Security Number. Provide your contact information including home and work phone numbers and street address.
- In the middle section, indicate who is authorized to receive the PHI by checking the appropriate box. Specify the purpose of disclosure such as continued care or personal use.
- Describe the specific records needed by providing treatment dates and checking relevant documentation types. Initial next to any highly confidential information you wish to disclose.
- Sign and date the form to validate it. If applicable, have a legal representative sign and indicate their relationship to you.
- Finally, choose how you would like to receive your PHI: by mail, pickup, or fax.
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How do I contact Summerlin hospital?
702-233-7000 We are happy to address questions regarding the hospital and the services we offer.
What is an authorization to use and disclose PHI?
Authorization. A covered entity must obtain the individuals written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.
How to access medical records from a hospital?
How you make your request will depend on your providers processes. You may be able to request your record through your providers patient portal. You may have to fill out a form called a health or medical record release form, or request for accesssend an email, or mail or fax a letter to your provider.
How to fill out authorization to use and disclose health information?
Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.
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