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Form preview Epcr short form Commonwealth of Virginia EMS Medical Record - Short Form Patient and Response Information Agency: Agency #: Unit #: Date: D D / D D / Y Y ZIP Location: Incident #: Times (24hr Format) Gender: ? Male
Form preview Mount sinai medical form 2013... Date Signature Personal Representative PRINT NAME Authority Need By Reason Send completed form to the most appropriate area listed below Mount Sinai Hospital Medical Records One Gustave L. Levy Place Box 1111 New York N.Y. PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient s Name Last Unit Number First Middle DOB Tel* No* / Month/Day/Year Address Street City State Zip Code Please request/check all that apply ACCESS REQUESTED on-site inspection record copy. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. PATIENT UNDERSTANDING AND SIGNATURE By signing below I am requesting that Mount Sinai provide me with access to health information in the manner described above. I understand that I will be contacted if any fees for a summary or explanation may be charged for fulfilling this request and that I will have an opportunity to modify or withdraw my request if I do not want to pay those fees. 10029 FPA Patient Rights Coordinator th 25-10 30 Avenue Long Island City NY 11102 Northshore Medical Group 325 Park Avenue Huntington NY Huntington NY 11743 For Hospital Use Only Date Received MO/DY/YR Disposition of Request / GRANTED DENIED Patient Notified in Writing Of Response On This Date MO/DY/YR PARTIALLY DENIED / Fee Charged For Fulfilling This Request if applicable Name or Initials of Records Department Staff Member Processing This Request Mail Out Will Pick Up 2 - Patient Copy. PATIENT ACCESS REQUEST FOR MEDICAL INFORMATION Patient s Name Last Unit Number First Middle DOB Tel* No* / Month/Day/Year Address Street City State Zip Code Please request/check all that apply ACCESS REQUESTED on-site inspection record copy. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. 75/page Records Bill Entire Designated Record Set Inpatient Visit s Date s of Service Document s ED Visit s Ambulatory Surgery Outpatient Clinic Manhattan AHC Dialysis IMA Jack Martin NRC OB/GYN Pediatrics Psychiatry Radiation Oncology Specialty Family Health Associates Senior Health Center Industrial Health Center FPA Practice/Provider X-ray Films/Reports Pathology Slides/Reports Other MR-200 Rev 1/13 We will not condition treatment or payment on whether you sign this authorization* However if you refuse to sign we will not release your records. PATIENT UNDERSTANDING AND SIGNATURE By signing below I am requesting that Mount Sinai provide me with access to health information in the manner described above.
Form preview Medical formpptx UNIVERSITY OF SOUTH FLORIDA Festival of Winds School of Music 4202 East Fowler Avenue, MUS101 Tampa, Florida 33620 Phone (813) 974-2311 Fax (813) 974-8721 Authorization for Treatment Student s Name
Form preview Emergency medical form olentan... OLENTANGY LOCAL SCHOOLS EMERGENCY MEDICAL AUTHORIZATION FORM Student Name: Birth Date: Grade: Address: Student lives with: City/Zip Code: Home Phone Number: PARENT/GUARDIAN(S) AND EMERGENCY CONTACTS
Form preview Medical document form I the health care practitioner acknowledge that the faxed medical document is now the original medical document and that I have retained a copy of this document for my records only. If you choose to submit the medical document by secure fax initial the statement below to acknowledge agreement. A health care practitioner includes medical practitioners and nurse practitioners. In order to be eligible to provide a medical document the health care practitioner must have the applicant for the medical document under their professional treatment. Regardless of whether or not this form is used the medical document must contain all of the required information see in particular s. Date Signed DD/MM/YYYY NOTE The medical document can be submitted from the health care practitioner s office to the licensed producer by secure fax. Sample Medical Document for the Access to Cannabis for Medical Purposes Regulations This document may be completed by the applicant s health care practitioner as defined in the Access to Cannabis for Medical Purposes Regulations ACMPR. 8 of the ACMPR. Patient s Given Name and Surname Patient s Date of Birth DD/MM/YYYY Daily quantity of dried marihuana to be used by the patient g/day The period of use is day s week s month s. NOTE The period of use cannot exceed one year Health care practitioner s given name and surname Profession Full business address of the location at which the patient consulted the health care practitioner if different that above Phone Number Fax Number if applicable Email Address if applicable Province s Authorized to Practice in By signing this document the health care practitioner is attesting that the information contained in this document is correct and complete. 8 of the ACMPR. Patient s Given Name and Surname Patient s Date of Birth DD/MM/YYYY Daily quantity of dried marihuana to be used by the patient g/day The period of use is day s week s month s. NOTE The period of use cannot exceed one year Health care practitioner s given name and surname Profession Full business address of the location at which the patient consulted the health care practitioner if different that above Phone Number Fax Number if applicable Email Address if applicable Province s Authorized to Practice in By signing this document the health care practitioner is attesting that the information contained in this document is correct and complete.
Form preview Medical form pdf pancare of fl... Patient MEDICAL Intake Form Instructions: 1. Print this form (excluding this cover page). 2. Complete the form then call our Community Health Center listed on the right for which you wish to make
Form preview Vanderbilt medical form 2015 2... 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 administrative authorization release of medical information Please complete all pages of this form sign and return to Vanderbilt Psychiatric Hospital Medical Information Services Attn Release of Information 1601 23rd Ave. The release of patient medical information is governed under federal and state laws. To release your medical information from Vanderbilt University Medical Center you must Complete all sections of the Authorization for Release of Medical Information form. Hand-deliver mail or fax a signed request in writing to VUMC Attn Release of Information. If you are under the age of 18 your parent or legal guardian must sign as well. What we will provide to the patient at no cost For patient Walk-in requests only. Authorization for Release of Medical Information Billing Fees Vanderbilt University Medical Center Medical Information Services 4560 Trousdale Drive Suite 101 Nashville TN 37204 records. At no cost to you we will provide up to 50 pages of the medical records that are relevant to your care. This is called an abstract. If you want additional records you will need to specify which ones on Page 1. What is an abstract An abstract contains only the medical records needed by you and your providers to continue your care after discharge. This is what is released unless you ask for your legal medical record. The abstract usually includes Discharge Summary History Physical Lab Pathology Operative Reports Procedure Notes Radiology Reports Problem List and Medications. What is a legal medical record In addition to what is in the abstract your legal medical record has all the information needed to identify you support your diagnosis justify your treatment and document your care and results. If you want your records sent to someone other than your doctor or for your own personal use you must complete and sign an authorization* Also you or the person receiving the records must agree to pay the fees. Here are the fees based on Tennessee Code Annotated 68-11-304 a 2 0. 85 per page for 1 to 50 page. 060 per page for 51 to 250 pages 0. 50 per electronic photograph Plus postage and any taxes that may apply If you would like to know in advance if the fee will be more than a certain amount indicate this here Let me know if the fee for my records will be more than. I understand that there may be fees for copying my medical records. By signing below I agree to pay these fees when I am billed for them by HealthPort. Name Phone Address Street City State Zip Signature Date Not Part of Permanent Medical Record Please contact the following departments directly if your request for information is related to home care services radiology/imaging services pharmacy services or financial records. HOME CARE SERVICES 2120 Belcourt Avenue Nashville TN 37212 615 936-0336 PHARMACY Outpatient 1301 22nd Ave.
Form preview Md medical form 2013 MARYLAND DEPARTMENT OF HUMAN RESOURCES MEDICAL REPORT FORM Department of Social Services Name and Address Agency Use Only- CASE IDENTIFICATION CUSTOMER ID NUMBER DIST CASE NAME Return to LDSS by:
Form preview High adventure activity medica... High Adventure Activity Medical Form Attach to Participants Health and Medical Form (Valid for 12 months from the date signed) Participant Name DOB: / / Age Emergency Contact Name Phone # Health Examination
Form preview New patient documents medical... NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE YOURCOMPLETED INTAKE QUESTIONNAIRE HELPS OUR PROVIDERS UNDERSTAND YOUR MEDICAL HISTORY. W E RELY ON ITS ACCURACY AND COMPLETENESS TO PROVIDE YOU WITH THE
Form preview Doctor medical forms Also list any medicine you take only on occasion like . Medication Brand and Generic Name Dose How and How Often You Take the Medication Reason for taking Date Started Check here if additional pages of medicine list attached Prescriber Continuation of List of Current Medications Page of Universal Medication Form Instructions for Use ALWAYS KEEP THIS FORM WITH YOU. Name UNIVERSAL MEDICATION FORM Always keep this form with you. Instructions on page 4. Date of Birth Sex circle one Male Female Height Address Phone Number s Home Work Emergency Contact Relation Mobile Phone Doctor / Dentist / Other Prescriber s Name Type of Practitioner / Reason for Seeing Pharmacy Name Street/City/State Allergies please describe reaction Immunizations Date of Last Dose Tetanus Pneumonia Vaccine Additional Information / Comments Flu Vaccine Hepatitis Vaccine Other Page 1 of Date Updated LIST OF CURRENT MEDICATIONS List all tablets patches drops ointments injections etc. Include prescription over-the-counter herbal vitamin and diet supplement products. Keep it in your wallet. Give a copy to your emergency contact another family member or friend. Take it with you when you pick up prescriptions. and ALL hospital visits. Allergies. List any reaction you have experienced from medicines that required you to stop taking that medicine such as allergies or bad side effects. Also include any allergy to dye food or insects etc* Also write what happens to you if you are exposed to these things. case they need to be contacted about your medicines. Pharmacy. List their names phone number and location in case there are questions. List of medicines. Write the brand and generic name of each medicine your dose how often and how by mouth under your tongue injection etc you take it. If you stop taking a certain medicine draw a line through it and list the date you stopped taking it. If you need extra pages remember to write your name on each one. List all tablets patches drops ointments injections etc* Include prescription over-the-counter herbal vitamin and diet supplement products. Also list any medicine you take only on occasion or as needed* like Motrin Aleve Tylenol . Hospital visits. Always ask your nurse pharmacist or doctor to help you update your list when you leave the hospital* You need to know what medicines to take and what to stop taking. Keep it in your wallet. Give a copy to your emergency contact another family member or friend. Take it with you when you pick up prescriptions. and ALL hospital visits. Allergies. List any reaction you have experienced from medicines that required you to stop taking that medicine such as allergies or bad side effects. and ALL hospital visits. Allergies. List any reaction you have experienced from medicines that required you to stop taking that medicine such as allergies or bad side effects. Also include any allergy to dye food or insects etc* Also write what happens to you if you are exposed to these things.
Form preview Emergency medical form for adu... ADULT EMERGENCY CONTACT AND MEDICAL FORM The information requested on this page is confidential and for emergency use only. In the event of an emergency this information will be used by program staff and emergency personnel. Please be honest when completing this form. SECTION 1. BASIC CONTACT INFORMATION Adult s Last Name Adult s Middle Name Home Address City Telephone 1 State Zip Code Date of Birth IN CASE OF EMERGENCY CONTACT Name Relationship Street Address ADULT S PHYSICIAN Phone SECTION 2. BASIC CONTACT INFORMATION Adult s Last Name Adult s Middle Name Home Address City Telephone 1 State Zip Code Date of Birth IN CASE OF EMERGENCY CONTACT Name Relationship Street Address ADULT S PHYSICIAN Phone SECTION 2. INSURANCE INFORMATION Please attach a photocopy of the policy holder s insurance card as proof of insurance. In the event of an emergency this information will be used by program staff and emergency personnel* Please be honest when completing this form* SECTION 1. INSURANCE INFORMATION Please attach a photocopy of the policy holder s insurance card as proof of insurance. Insurance Carrier Group or Policy Address for Claims Policy Holder s Name SECTION 3. HEALTH INFORMATION Are you allergic to anything No* Yes Please list all allergies. Are you taking any medication Do you have any medical/mobility/mental health concerns of which we should be aware should be known to program staff and medical personnel* If I am unable to give consent in the event of an emergency I hereby give permission to medical personnel to administer emergency medical treatment. Signature Print Name Date Participant Liability and Photo Release Form I hereby release indemnify and hold harmless Warren Wilson College the Exploring Joara Foundation Tulane University University of Michigan Western Piedmont Community College and their respective officers directors employees agents contractors subcontractors representatives successors and assigns and all persons conducting directly or indirectly the activities surrounding my involvement as a program participant from any and all claims rights demands actions causes of action expenses and damages which I or my heirs personal representative successors assigns or anyone claiming by through or under me ever had now have or may have against the parties identified above arising from any injury act or omission relating in the way to my participation as a program participant. I understand that I will not be entitled to and will not receive Worker s Compensations benefits or other similar payments from Warren Wilson College the Exploring Joara Foundation Tulane University University of Michigan or Western Piedmont Community College under the law of the State of North Carolina in the event that I am injured* I hereby provide consent to these institutions to copyright publish use sell or assign any and all photographic portraits or pictures television spots movie films videotapes and/or sound records or any part thereof that they may take or make of me during my time as a program participant in which I may be included in whole or in part whether separate from or in conjunction with illustrative or written manner story or news item motion pictures television or radio spots or for publicity advertising or any other lawful purpose whatsoever in and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied* I hereby waive all claims for compensation of such use or for damages.

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