Northwestern Medical Faculty Foundation, Inc.


Health Information Management Medical Records
675 North St. Clair Street | Suite 17-150 Chicago, | Illinois 60611
Tel (312) 695-8642 | Fax (312) 695-1940 | www.nmff.org



AUTHORIZATION FOR DISCLOSURE OF INFORMATION

PATIENT INFORMATION



LAST


FIRST


M.I.


BIRTHDATE



STREET ADDRESS



CITY



STATE



ZIP CODE



HOME PHONE NUMBER



WORK PHONE NUMBER


INFORMATION RELEASE TO:



NAME (i.e. Health Care Facility, Insurance Co., Attorney, Self..)



STREET ADDRESS



CITY



STATE



ZIP CODE



PHONE NUMBER

I authorize the disclosure of my health information by NMFF as described below (check all that apply):
  Main Volume only
  Genetics
  Neurosurgery
  Anesthesiology/Pain
  Geriatrics
  Ob/Gyn
  Cardiology
  Hem/One
  Plastic Surgery
  Cardiothoracic Surgery
  Neurobehavior
  Transplant
  Urology

DATES OF SERVICE FROM TO

SPECIAL INSTRUCTIONS (SPECIFIC INFORMATION COPIES, i.e. Lab only, etc.
  Psychiatry (I understand that a special form is required, and I will need to contact the department of psychiatry at (312) 695-1838)
  Billing          HMO (if applicable)

  I would like an appointment to review my medical records.
Unless checked below I understand that this information may include information relating to:
  AIDS (Acquired Immunodeficiency Syndrome) or HIV (Human Immunodeficiency Virus) infection   Genetic Information

PURPOSE OR NEED FOR DISCLOSURE (CHECK ALL THAT APPLY)
  At the request of the patient indicated above               Continuity of Care
  Other

INABILITY TO WITHHOLD TREATMENT, PAYMENT ENROLLMENT, OR ELIGIBILITY BENEFITS ON EXECUTION OF THIS AUTHORIZATION
I understand that NMFF may not withhold treatment, payment, enrollment, or eligibility for benefits, on my executing this authorization except NMFF may withhold health care that is solely for the purpose of creating health information for disclosure to a third party.

RIGHT TO REVOKE
I understand that I have the right to revoke this authorization. I understand that my revocation must be in writing. I also understand that my revocation will be valid except to the extent that NMFF has taken action in reliance on this authorization. For information on how to revoke this authorization, contact the NMFF Medical Records Department at (312) 695-8642.

REDISCLOSURE
I understand that once the authorized organization or person receives this information, then it may be subject to redisclosure by the recipient and may no longer be protected by federal privacy laws. However, I understand that Illinois law prohibits redisclosure of HIV information, if any, and genetic information by the recipient except as otherwise allowed by law. NMFF is not responsible for ensuring that any recipient of your individually identifiable health information will further use and/or disclose the information for the purposes set forth in this authorization.

EXPIRATION
If not revoked, this authorization is valid for six months from the date of signature.
I understand that there may be a charge for copies of records. For information regarding the current fee schedule please call Medical Records.

SIGNATURE
By signing below I acknowledge and affirm the statements in this authorization form.


Signature:
If being executed by a representative on behalf of a patient,
please indicated your relationship to the patient:


RELATIONSHIP
MR USE ONLY

NMFF MR#:
Date copied: Initials:



RELEASE OF INFORMATION COPYING FEES

EFFECTIVE September 1, 2001 Public Act 92-0228

The copying fee for anyone requesting records (i.e., patients, attorneys, insurance carriers, etc.) is:

$20   
$0.75
$0.50
$0.25
$      
handling charge for processing the request for copies
per page for the first 25 pages
per page for the 26-50 pages
per page for all pages in excess of 50
actual shipping charges

VIEWING FEES (Patients to view their records)

$10
$50
Prepay to view the medical record for the first 30 minutes
additional fee for each additional hour

This excludes government agencies such as DORS, and subpoenas issued by the courts in which the fee remains $20.

Subpoenas issued through a copy service must pay the standard fee listed above, the $20 fee is unacceptable.

When quoting the $25 prepay fee, state to the requestor that this only covers the first 6 pages, and additional amounts will be billed. Also remember that if you only copy 2 pages and we have received the $25 prepay fee, we have not billed for shipping costs


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