It should be completed on an official signed page such as a notarized letter, faxed letter, or scanned in, and signed under penalty of perjury.
Provide a personal identification number (PIN) that will be required as a part of the release.
Obtain authorization for your health information from the person authorizing its release, if other than the parent.
Provide any other information requested during the online authorization.
Provide documentation of your identity or proof of address (such as a recent utility bill, bank statement, rental lease, etc.). You will be asked for basic personal details, as well as information about how you intend to use the records.
Receive a copy of the Authorization for Release of Medical Information form.
Once an authorized release is made, please report any discrepancies to the Office of Data Security and Information Assurance using the Online Authorization for Update of PHI.
Once you receive the Authorization for Release of Medical Information, you or your primary caregiver will need to authorize changes or updates in your records. The process of updating your records depends on which parent signed the Authorization for Release of Medical Information.
MC 3916 2012 free printable template
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MEDICAL RECORD INCLUDES RECORDS FROM Vanderbilt University Hospital Monroe Carell Jr. Children s Hospital at Psychiatric Hospital Vanderbilt Medical Group If yes this is the only item you may request on this authorization. You must submit a If no you may check any items below. In this case the information may no longer be protected by the HIPAA/Privacy Rule. Treatment cannot be withheld or based on getting this authorization. Medical Record FOR STAFF USE ONLY Please complete all pages of...
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