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Medical Records
AUTHORIZATION TO DISCLOSE HEALTH
INFORMATION Form
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Inspection and Copies: You have the
right to inspect and obtain a copy of the health
information that may be used to make decisions about
you, including patient health records and billing
records. You may also request that your records be sent
to another person(s) or provider of health care. You must
submit your request in writing to Mammoth Hospital,
Health Information Management Services, Release of
Information, P.O. Box 660, Mammoth Lakes, CA 93546,
(760) 934-3311 ext. 2378 in order to inspect and/or
obtain a copy of your health information. Mammoth
Hospital may charge a fee for the costs of copying,
mailing, labor and supplies associated with your
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request. Mammoth Hospital may deny your request to
inspect and/or copy in certain limited circumstances;
however, you may request a review of our denial. Another
licensed health care professional chosen by us will
conduct reviews.
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Authorization to Disclose Health Information Form
Autorización para proporcionar información médica
REQUEST FOR LIMITATIONS & RESTRICTIONS OF
PHI Form
Requesting Restrictions: You have the
right to request a restriction in our use or disclosure
of your health information for treatment, payment or
health care operations. Additionally, you have the right
to request that we restrict our disclosure of your
health information to only certain individuals involved
in your care or the payment for your care, such as
family members and friends. We are not required to agree
to your request; however, if we do agree, we are bound
by our agreement except when otherwise required by law,
in emergencies, or when the information is necessary to
treat you. In order to request a restriction in our use
or disclosure of your health information, you must make
your request in writing to Mammoth Hospital, Privacy
Officer, P.O. Box 660, Mammoth Lakes, CA 93546. Your
request must describe in a clear and concise fashion (1)
the information you wish restricted; (2) whether you are
requesting to limit our practice’s use, disclosure or
both; and (3) to whom you want the limits to apply, for
example, disclosures to your spouse.
Request for Limitations & Restrictions of Protected Health Information Form
Solicitud De Limitaciones Y Restricciones De La Información Protegida Concerniente A La Salud
REQUEST FOR CORRECTION/AMENDMENT OF
HEALTH INFO Form
Amendment: You may ask us to amend your
health information if you believe it is incorrect or
incomplete, and you may request an amendment for as long
as the information is kept by or for Mammoth Hospital.
To request an amendment, your request must be made in
writing and submitted to Mammoth Hospital, Privacy
Officer, P.O. Box 660, Mammoth Lakes, CA 93546. You must
provide us with a reason that supports your request for
amendment. Mammoth Hospital will deny your request if
you fail to submit your request (and the reason
supporting your request) in writing. Also, we may deny
your request if you ask us to amend information that is
in our opinion: (a) accurate and complete; (b) not part
of the health information kept by or for the practice;
(c) not part of the health information which you would
be permitted to inspect and copy; or (d) not created by
our practice, unless the individual or entity that
created the information is not available to amend the
information.
Even if we deny your request for
amendment, you have the right to submit a written
addendum, not to exceed 250 words, with respect to any
item or statement in your record you believe is
incomplete or incorrect. If you clearly indicate in
writing that you want the addendum to be made part of
your health record we will attach it to your records and
include it whenever we make a disclosure of the item or
statement you believe to be incomplete or incorrect.
Request for Correction/Amendment of Health Information Form
Solicitud de corrección o enmienda de información concerniente a la salud
REQUEST FOR RESTRICTION ON THE
MANNER/METHOD OF CONFIDENTIAL COMMUNICATIONS Form
Confidential Communications: You have
the right to request that Mammoth Hospital communicate
with you about your health and related issues in a
particular manner or at a certain location. For example,
you may ask that we contact you at home, rather than
work. In order to request a type of confidential
communication, you must make a written request to
Mammoth Hospital, Privacy Officer, P.O. Box 660, Mammoth
Lakes, CA 93546 specifying the requested method of
contact, or the location where you wish to be contacted.
Our practice will accommodate reasonable requests. You
do not need to give a reason for your request.
Request for Restriction on the Manner/Method of Confidential Communications Form
Solicitud De Restricción En La Forma O En El Método De Envío De Comunicaciones Confidenciales
REQUEST FOR ACCOUNTING OF DISCLOSURE Form
Accounting of Disclosures: All of our
patients have the right to request an “accounting of
disclosures.” An “accounting of disclosures” is a list
of certain non-routine disclosures our practice has made
of your health information for non-treatment or
operations purposes. Use of your health information as
part of the routine patient care in Mammoth Hospital is
not required to be documented. For example, a doctor
sharing information with the nurse; or the billing
department using your information to file your insurance
claim. In order to obtain an accounting of disclosures,
you must submit your request in writing to Mammoth
Hospital, Health Information Management Services,
Release of Information, P.O. Box 660, Mammoth Lakes, CA
93546. All requests for an “accounting of disclosures”
must state a time period, which may not be longer than
six (6) years from the date of disclosure and may not
include dates before April 14, 2003. The first list you
request within a 12-month period is free of charge, but
our practice may charge you for additional lists within
the same 12-month period.
Mammoth Hospital will notify you of the
costs involved with additional requests, and you may
withdraw your request before you incur any costs.
Request for Accounting of Disclosure Form
Solicitud Del Estado De Cuenta De Revelaciones De
Informacion Protegida De Su Salud
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