NAME DATE of BIRTH PATIENT AT INTEGRITY btw AND 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your NAME in the designated field. Ensure that it is spelled correctly for accurate record-keeping.
  3. Next, fill in your DATE of BIRTH. Use the format specified on the form to avoid any confusion.
  4. In the section labeled 'PATIENT AT INTEGRITY btw', indicate the time frame by filling in both start and end Month/Year fields.
  5. Check all applicable boxes regarding your records preferences, whether you want them emailed or printed, and note any associated fees.
  6. If you wish to release your information to another person, check the appropriate box and attach necessary documents like Power of Attorney if applicable.
  7. Select your payment method and calculate the TOTAL amount due based on your selections.
  8. Finally, provide contact details for any medical providers receiving records and ensure you sign and date the form before submission.

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Definition: The month, day, and year the patient was born. Note: Patients age (in years) is calculated by Admission Date minus Birthdate.
A date of birth is not PHI when it is maintained separately from other information because it does not identify the individual to whom the date relates.
In most circumstances, saying a patients name by itself is not a HIPAA violation when the name does not relate to the patients health condition, treatment for the condition, or payment for the treatment. However, there are some circumstances in which saying a patient name is a HIPAA violation.
Protected health information includes many common identifiers (e.g., name, address, birth date, Social Security Number) when they can be associated with the health information listed above.

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