| Clymer Healing Center |
Woodlands Healing |
|
5916 Clymer Rd., Quakertown, PA 18951 * 215-536-8001 * Fax 215-536-9099 |
5724 Clymer Rd., Quakertown, PA 18951 * 215-536-1890 * Fax 215-529-9034 |
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HIPPA Permission for Release of Information
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Date: 01/01/2003 |
In order to comply with specific rules regarding HIPAA (Health Insurance Portability & Accountability Act of
1996), we ask that our patients complete and sign this privacy and security of health information document.
| Patient Name: | Date: | ||
| Personal Representative Name: | Relationship: |
It is the office policy of Woodlands Healing Research Center not to release confidential and/or unauthorized information by home telephone, answering machine, work telephone, voicemail, or cell phone. Whenever returning telephone calls and the answering machine picks up we cannot leave a message if the name and telephone number is not on the recorded message to identify the residence. Information will also not be left with an unauthorized person who may answer the telephone.
I authorize Woodlands Healing Research Center and staff to leave medical information pertaining to my care by the following methods and will assume responsibility of notifying Woodlands Healing Research Center whenever this information changes.
| Home Telephone | Yes | No | Not Applicable |
| Answering Machine | Yes | No | Not Applicable |
| Work
Telephone, #: |
Yes | No | Not Applicable |
| Voice mail | Yes | No | Not Applicable |
| Cell
Phone/Cell Voicemail, #: |
Yes | No | Not Applicable |
| Work Fax,
#: |
Yes | No | Not Applicable |
| Home
Fax, #: |
Yes | No | Not Applicable |
| E-Mail,
Address: |
Yes | No | Not Applicable |
Patient must sign appropriate release of information before health information will be sent to the following:
| Other Physician Office | Yes | No | |
| Insurance Company | Yes | No | |
| Work
Telephone, #: |
Yes | No | |
If you would like to have information released to someone other than yourself, please complete the following:
Please list names of people authorized to receive your health information:
| Spouse Name: | Yes | No | |
| Mother's Name: | Yes | No | |
| Father's Name: | Yes | No |
| Other Names: | Relation: | ||
| Yes | No | ||
| Yes | No | ||
| Yes | No | ||
| Yes | No |
| Date: | Patient/Guardian Signature: |