Identification and address of patient or the person whose health information is to be released:
Name:
Social Security Number: Date of Birth: Medical Record Number:
P.O. Box, Apt No., Street Town State Zip
Is patient being referred to: Hypertension Program?_____ __________________ Diabetes Program? ________
Contact phone #s
Clinic Assigned:____________________________
Marital Status:______ ญญญญญญญญญญญญญญญญญ Employed:_________ {1) JMM, 2) UNACARE, 3) Other UHC Clinic}
I hereby authorize UHC to release, Information in its care, custody or control, such as consultation reports, notes, records and information concerning diagnosis, treatment, consultations, prognoses and impressions of my physical health, to:
Hinds County Health Alliance and/or its attorneys or agents
350 Woodrow Wilson Drive
Suite 615
Jackson, MS 39213
Reason for disclosure:
To supply Hinds County Health Alliance and or its attorneys or agents the information they will need to facilitate and expedite referrals for my care when the need arises.
Description of your rights regarding this authorization:
1. You have the right to refuse to sign this authorization;
2. You may inspect or copy the protected health information to be disclosed for as long as UHC maintains that information with some exceptions; and
3. You have the right to take away the authorization at any time by doing the following:
A. Send to UHC a written notice that is signed and dated by the patient or person whose health information was to be released. The notice should have the following information on it:
ท Your name and address, social security number, medical record number if known and date of birth;
ท A description of the health information that UHC was authorized to release;
ท The name or other specific identification of the person(s), or class of persons, that UHC was going to send the information to; and
ท The date that the authorization was signed.
B.
Send the written statement to the
following address
University of Mississippi Medical Center
The only time that UHC will not honor a written notice to take away an authorization is if UHC has already released the information described in the authorization before UHC received the written notice.