Authorization to Release Patient Medical Information to Capital Women's Care

Capital Women's Care - 2000 Medical Parkway, Suite 310 Annapolis Md 21401
Phone - 410-266-7755
Fax - 410-266-1141

I hereby authorize to use and disclose my individually identifiable Protected Health Information (PHI) to Capital Women’s Care in the manner described below.

I understand that I have the right to access my complete medical records maintained by Capital Women’s Care, based on the federal HIPAA law. I understand that when I am requesting a copy (electronic or hardcopy) of my records, or wishing to send my records to a third-party, I will be asked to sign this form. I also understand that my PHI may be re-disclosed by the person or entity receiving my PHI from CWC, and that it then may no longer be protected by federal privacy regulations. Maryland law allows for such re- disclosure by Capital Women’s Care if it is authorized by the person in interest (patient).? I voluntarily sign this authorization, and I understand that my health care will not be affected if I do not sign this form. I understand that Capital Women’s Care reserves the right according to their HIPAA Practicing Guidelines to use a third-party vendor to process requests for production or to copy medical records containing PHI - information.

TYPE OF INFORMATION TO BE RELEASED/COPIED/PROVIDED BY CAPITAL WOMEN’S CARE:

1. GENERAL RELEASE: I would like to obtain copies of the following:

Records in Capital Women’s Care’s Designated Record Set’, excluding information the patient does not have a “Right to Access”

Please Check ONE:

TYPE OF INFORMATION NOT TO BE RELEASED/COPIED/PROVIDED BY CAPITAL WOMEN’S CARE:

2. CONFIDENTIAL INFORMATION PROTECTED BY STATE/FEDERAL LAW: I would like the following information excluded from the information released:

An individual does not have a right to access PHI that is not part of a designated record set because the information is not used to make decisions about individuals. This may include certain quality assessment or improvement records, patient safety activity records, or business planning, development, and management records that are used for business decisions. In addition, two categories of information are expressly excluded from the right of access: Psychotherapy notes, and information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. See 45 CFR 164.524(a)(1)(ii).

2 HEALTH-GENERAL ARTICLE § § 4-301--4-309, 8-601

3 A “Designated Record Set” is defined by HIPAA as a group of records maintained by a covered entity that may include patient records, bills, information maintained by medical management record systems, or information used to make care-related decisions.

4 External records include but are not limited to Special Outside Correspondence. Such records are records created by non-Capital Women’s Care providers, sent to Capital Women’s Care, and added into the patient’s electronic health record. This information is supplied to Capital Women’s Care but, per our Designated Record Set policy, it is not included in our Legal Medical Record and shall be supplied to patients only upon request.

PATIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION

I certify that I have read, signed, and received a copy of this authorization upon my request or at the request of a representative legally authorized to make this request on my behalf. I understand that I may be billed for copies of my medical records from the entity sending them to Capital Women’s Care according to applicable state and federal laws and guidelines. I understand that I have the right to receive a copy of this authorization. I also understand this authorization is valid for ninety (90) days only and may be revoked in writing at any time prior by notifying the entity releasing information in writing. I understand I have the right to revoke the authorization at any time except to the extent that action has been taken in reliance thereon.

PATIENT INFORMATION

INFORMATION OF ENTITY SENDING REQUEST TO CWC

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.