AUTHORIZATION TO USE OR DISCLOSE
PROTECTED HEALTH INFORMATION
South Shore Hospital
55 Fogg Road, Box 55
S. Weymouth, Ma 02190
781-624-8843
First Name:
DOB:
City:
Zip:
1.
Patient Last Name:
Patient
Street Addre
ss:
Patient
Phone
:
State:
2.
FROM:
South Shore Hospital Other: (specify below)
Name:
Address:
Phone#:
Fax #:
Privileged or specifically protected information requires specific consent when present in the patient record:
I am authorizing the release of the following information by INITIALING each appropriate category.
______Alcohol and Drug Abuse
I understand that if my records are protected under the
Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient
Records, 42 CFR Part 2, they cannot be disclosed without my written consent unless otherwise provided for in the regulations.
4.
Discharge Summary
Mental Health Consult
Mental Health Progress Note
Addiction Medicine Consult
Addiction Medicine Progress Note
X-Ray/Radiology Reports
Laboratory Reports
Therapy (Physical/Occupational)
Consults
Pathology Results
Emergency Reports
CD (X-Ray, MRI, CT Scan)
Complete Record (Not Including CD)
Outpatient Notes
Other Specify):_________________
_____Mental Health
_____HIV/AIDS/Results/Treatment
_____Sexual Transmitted Diseases
_____Domestic
Violence Victim's Counseling
_____Abortion
SSH6230-033_July 2021
Medical Record Number (if known):
_____Communication with a licensed Social Worker
_____Sexual Assault Victim's Counseling
_____Genetic Testing
*CON0028*
Page 1 of 2
I give my permission to share my protected health information from my medical record as indicated below
Abstract (Includes History & Physical, Operative Reports, Consults, Test Results, Discharge Summary, Emergency Reports)
Purpose:
Medical Care
Insurance*
Legal Matter*
Personal*
Other (specify)*
*Copying fees may apply
3.
TO: (recipient of records. Note "self" if sending to patient address)
Name:
Address:
Phone #:
Fax#: (For Health Care Facilities/Providers)
HIM Method of Record Delivery (Choose One):
Email:
South Shore Health MyChart (if applicable)
Paper Copy via mail to the address noted above
CD sent via mail to the address noted above
Complete Section if applicable for releasing medical records:
Information to be released for treatment dates: From:______ /______ /______ Through:______/______/______
I authorize the disclosure of the following information which may be included in my record. Specify records, by
checking.
OTHER IMPORTANT INFORMATION
Signature of Patient or Authorized Representative
Date
Printed Name of Patient or Legal Representative
Relationship to patient or authority to act for patient
2.
3.
Patient Last Name:
First Name:
DOB:
/
Page 2 of 2
1.
5.
I may refuse to sign this authorization. I understand that my refusal will not affect my ability to obtain treatment at South Shore Health (SSH)
unless (a) the only purpose of the treatment is to create health information for the disclosure noted above; or (b) if my treatment is related to
participation in a research study for which this authorization is required.
Once SSH has disclosed my health information to an authorized recipient, SSH cannot guarantee that the recipient will not re-disclose my health
information to a third party.
I understand that I may revoke this Authorization in writing at any time, except that the revocation will not have any effect on any action
taken by the Provider before the Provider received written notice of revocation. I further understand that I must provide any notice of
revocation in writing to the Privacy Officer of South Shore Hospital at 55 Fogg Road, Mailbox #82, South Weymouth, MA 02190.
This authorization will expire within one year unless revoked.
I understand that I may be charged a fee for reproduction of requested health information. This fee will comply with Massachusetts Law
Chapter 111, § 70 with regard to the inspection and copying of medical records.
If I have any questions about disclosure of my health information, I can contact Health Information Management Department at (781) 624-8843.
The completed form can be mailed to Health Information Management Department 55 Fogg Road, Box 55 S.Weymouth, MA 02190 or faxed to
(781) 624-3719.
4.
6.
SSH6230-033_July, 2021
/
5.Required Information:
SSH6230-033_July, 2021
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION INSTRUCTIONS:
The Authorization to Use or Disclose Protected Health Information form has a dual purpose. It can be
used when requesting medical records be released from South Shore Health or when requesting that
medical records be sent to South Shore Health from an outside entity. The form is generally used when
the patient or appointed legal representative is required to authorize the release or disclosure of medical
record information.
Incomplete and/or ill
egible forms are not valid and will be returned
for
completion.
If y
ou
have
any
questions please contact our
office.
Thank
you!
*Please note that record requests may be subject to a copying fee.
1. Please provide patient identifying information, including full name, date of birth, street
address, contact information and medical record number (if known).
2. In the FROM Box, indicate the entity or clinician that is providing the records (typically,
“South Shore Hospital”). Here you will also indicate the purpose or reason for the
request.
In the TO Box, indicate the entity or individual to whom you would like the records released
(for example: "Self" or “Doctor's Office" or "Attorney’s Name" or "Insurance Company Name").
Also indicate the manner in which you would like to receive the requested information; email,
South Shore Health MyChart, mail, fax (only applicable for Healthcare Facilities and/or
providers) or CD.
3. Indicate the treatment dates for which you would like the records released. (For example,
"Jan 1, 2014 to present."). Also indicate what type of records you would like released.
4. In order for this information to be released, you must initial each applicable item listed.
5. Please sign and date the form. Information cannot be released without an appropriate
authorized signature.
