Professional legal forms

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.

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:

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

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

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.

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.

Student medical form DOCUMENTATION FOR THE 2017-2018 SEASON FLU VACCINE IS REQUIRED FOR ... STUDENT MEDICAL FORM, OR USE A SEPARATE FORM. RETURN ...

New student emergency medical... STUDENT EMERGENCY MEDICAL FORM (Please print) STUDENTS NAME: SCHOOL YEAR DATE OF BIRTH PRESENT GRADE STUDENTS ADDRESS: PHONE # Purpose: To authorize the emergency treatment for the child who becomes

Medical form winston salem das... MEDICAL FORM WINSTONSALEM DASH YOUTH BASEBALL ACADEMY MEDICAL HISTORY, TREATMENT PERMISSION AND RELEASE Note: This form is required prior to participation in The WinstonSalem Dash Youth Baseball Academy.

Cuny baruch medical form One Bernard Baruch Way Box H-0880 New York, NY 10010-5585 Tel: 646-312-2050 Fax: 646-312-2051 http://www.baruch.cuny.edu caps baruch.cuny.edu INTERNATIONAL STUDENT SERVICE CENTER CONFIDENTIAL DECLARATION

Summit bechtel medical form Participant s Printed Name: Council & Unit: Arrival Date: MEDICAL CONSENT FORM PARTICIPANT ACKNOWLEDGEMENT In case of an emergency, I understand that every effort will be made to contact the individual

High adventure activity medica... High Adventure Activity Medical Form Attach to Participant s Health and Medical Form (Valid for 12 months from the date signed by the medical professional) Participant Name DOB: / / Age Emergency

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