Information Disclosure Form.doc - inova 2025

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The document is a Patient Record of Disclosures from the Inova Breast Care Center, outlining the patient's rights under HIPAA regarding the privacy of their protected health information (PHI). It includes sections for patients to specify their preferred methods of communication and to authorize sharing of their medical information with specific individuals. Additionally, it allows patients to list physicians who should receive reports of their visits.

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Click ‘Get Form’ to open the Information Disclosure Form in the editor.
Begin by entering your Patient Name and MRN (Medical Record Number) at the top of the form. This information is essential for identifying your records.
Fill in your Date of Birth (DOB) to ensure accurate processing of your request.
In the 'Patient Record of Disclosures' section, indicate how you wish to be contacted by checking all applicable options for home, work, and cell telephone communications.
Specify if it’s acceptable for messages to include detailed information or if only a call-back is preferred.
List any individuals with whom you authorize sharing your medical information, including their names, relationships, phone numbers, and addresses.
Provide the names and addresses of physicians who should receive a report of this visit in the designated section.
Finally, sign and date the form at the bottom before submitting it through our platform.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a consent to disclose form?

FERPA requires that a consent for disclosure of education records be signed and dated, specify the records that may be disclosed, state the purpose of the disclosure, and identify the party or class of parties to whom the disclosure may be made.

What is a consent form to release medical information?

A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, ing to the details stipulated in the form.

Why cant doctors share information?

The information contained in medical records is confidential under federal and state law. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that protects individually identifiable health information (or protected health information). It does so through the Privacy Rule.

What is the authorization for disclosure of information form used for?

A Privacy Rule Authorization is an individuals signed permission to allow a covered entity to use or disclose the individuals protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.

What are medical consent forms?

If you agree to receive all or some of the treatment options, you give your consent (agree) by signing a consent form. The completed and signed form is a legal document that lets your doctor go ahead with the treatment plan.