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How to use or fill out Request to Access Protected Health Information PHI - Concentra
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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name and birthdate in the designated fields. This information is crucial for identifying the correct medical records.
Fill in the patient's address to ensure proper delivery of the requested information.
Specify the purpose of disclosure and the facility visited, which helps clarify why you are requesting access to these records.
Select which records you wish to disclose by checking the appropriate boxes, such as complete medical record or lab results.
Provide details about who may receive copies of your records, including their name, address, and preferred method of receiving information (mail, fax, etc.).
If applicable, initial next to any sensitive information that may be included in your request.
Sign and date the form at the bottom. If a representative is signing on behalf of the patient, include their printed name and explanation of authority.
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Before employees can use Concentra Telemed, their employer must submit a treatment authorization on their behalf. This online authorization grants Concentra permission to treat employees for workers compensation injuries or illnesses using our telemedicine platform.
How do you request access to PHI?
Request by Patient to Access to Protected Health Information The patient has a right to access the Protected Health Information (PHI) maintained in his or her designated record set under both state and federal law.
Can a resident request access to their protected health information?
General Right. The Privacy Rule generally requires HIPAA covered entities (health plans and most health care providers) to provide individuals, upon request, with access to the protected health information (PHI) about them in one or more designated record sets maintained by or for the covered entity.
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Concentra - Employer Services-Authorization For Disclosure
I give Concentra authorization to release to my employer, insurance company, and/or their representatives any medical information, including any psychotherapy
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