The Health Information Management Services (Medical Records) Department is responsible for managing requests and releasing copies of medical records. Due to the confidential nature of a patient's medical record, Holy Name Medical Center requires ALL requests for the release of medical records be accompanied by a completed, HIPAA-compliant, Authorization for Release of Medical Information Form, signed by the patient or legal representative.
When completing an Authorization for Release of Medical Information Form.
- Who the records are being furnished to? Include the person's name, complete address, (department, room or suite number if applicable), and phone number.
- Demographic information of the patient. Include any aliases, married name, and date of birth.
- Nature of information to be released. Check the specific information requested, which is located under part 1 on the Authorization for Release of Medical Information Form.
- Dates of treatment. Enter the date range, which is located under part 2 on the Authorization for Release of Medical Information Form.
- Purpose for release. MUST be completed, which is located under part 3 on the Authorization for Release of Medical Information Form.
- Patient's signature. The signature of the patient or Legal Representative MUST BE NOTARIZED if not signed in person in the HIM Department. A copy of the legal paperwork (Health Care Proxy, Letters of Administration, Guardianship, etc) MUST accompany the request, if not sign by the patient.
Due to HIPAA regulations, your request will be returned to you and not be completed if any of the required information above is missing from the authorization form.