ROYAL OAK PEDIATRICS, PC

26657 WOODWARD AVENUE, SUITE 200 HUNTINGTON WOODS, MI 48070

248-398-8400

Authorization for Release of Medical Records

PATIENT INFORMATION REQUESTED:
 
  Patient Name:   DOB:  
  Address:   Phone:  
 
I AUTHORIZE ROYAL OAK PEDIATRICS TO: (CHECK ONE):
  Receive Medical Records From:  
  Receive Medical Records To:  
  Receive Medical Records for Personal Use To:  
 
 
TYPES OF RECORDS TO BE RELEASED: (CHECK ONE)
    Our records, including records from previous physicians  
    Specific information only:    
 
INITIAL ON THE LINE BELOW TO SHOW ACKNOWLEDGEMENT OF THE FOLLOWING: (INITIAL PREFERENCE)
 
  I understand that the information above may contain mental health, developmental disabliities, alcoholism, AIDS test results, AIDS-related desease diagnosis, drug abuse or other privileged information.  
 
  I do not wish to disclose information that may contain mental health, developmental disabilities, alcoholism, AIDS test results, AIDS-related disease diagnosis, drug abuse or other privileged information.  
 
REASON FOR REQUEST: (CHECK ONE)
    MOVING-PROVIDE NEW ADDRESS:    
    TRANSFER OF CARE-REASON:    
    OTHER-PLEASE SPECIFY:    
 
  Patient/Parent/Guardian:     Date:    
  Printed Name:     Relationship to Patient:    
 
 
  HIPAA is the acronym for the Health Insurance Portability and Accountability Act that was passed by Congress in 1996. HIPAA does the following:
  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
  • Reduces health care fraud and abuse;
  • Mandates industry-wide standards for health care information on electronic billing and Other processes; and
  • Requires the protection and confidential handling of protected health information
 
  The HIPAA Privacy regulations require health care providers and organizations, as well as their business associates, to develop and follow procedures that ensure the confidentiality and security of protected health information (PHI) when it is transferred, received, handle, or shared. This applies to all forms of PHI, including paper, oral, and electronic, etc. Furthermore, only the minimum health information necessary to conduct business is to be used or shared.  
 
  The Office of HIPAA Compliance (OHC) is the Department of Health Care Services’ (DHCS) office responsible for implementing the regulations of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. OHC is responsible for the project management, coordination and, in most cases, performance of Department HIPAA compliance activities through partnerships with DHCS program areas, Enterprise Innovation Technology Services (EITS), and Medi-Cal fiscal intermediaries.  
 
  OHC’s Information Protection Unit (IPU) and the Office of Legal Services’ Privacy Office work collaboratively with DHCS business associates, counties, and other state agencies, with whom we establish contractual relationships, to safeguard Protected Health Information (PHI) and Personally Identifiable Information (PII) and investigate privacy breaches and complaints involving unauthorized access or disclosure of PHI, PII, and confidential information.  
 
  Please ask the Front Desk for a copy of the full HIPAA Disclosure