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St. Francis Record Release

Authorization to Disclose Health Information: I, the undersigned, authorize _______ to release my health information as noted below:

Patient Information

Release Information To

A $.65 per page charge will be applied for all copies released directly to patient or authorized legal representative. The charge does not apply when the records are sent directly to a healthcare provider for ongoing treatment purposes

Information to be Released

Unless otherwise specified, only the following information will be released:

Inpatient/Same Day Abstract Includes: History and Physical, Discharge Summary (Inpatient only), Reports of Consultations and Operative Reports when applicable

ED Abstract includes: ED MD Documentation and Nursing Notes

Clinic / Diagnostic Treatment Visit: Note / Result from Date of Service

Behavioral Health Visit Abstract Includes: Discharge Summary, Biopsychosocial Assessment, and Psychiatric Evaluation

Authorization to Release Protected

*Required - Please complete the check boxes below indicating how protected information should be handled even if the categories do not necessarily apply lo the patient's medical records.

Check one:
Check one:
Check one:

STOP: Please confirm that you have checked and initialed all the protected information categories above regardless if they are applicable or not. If form is incomplete, or If the protected information is not checked and initialed, we may be unable to fulfill this request

  • This authorization will expire 180 days from the date appearing above. I understand that I may revoke this authorization at any time by notifying the Health Information Management Department in writing, but if I do, it will not have any effect on the actions the hospital took before it received the revocation.
  • I understand that under the applicable law the information used or described pursuant to this authorization may be subject to redisclosure by the recipient and no longer subject to the protections of the privacy standard.
  • I understand that my treatment or continued treatment by Saint Francis Hospital & Medical Center and its affiliates is no way conditioned on whether or not I sign the authorization and that I may refuse to sign ii.
  • I understand that I may inspect or copy the information that is used or disclosed.

Thank you for taking the time to fill out this form.

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Office Hours

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Office Hours

Our Regular Schedule

Monday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Tuesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Wednesday:

8:00 am-12:00 pm

1:00 pm-6:00 pm

Thursday:

8:00 am-11:00 am

11:30 am-1:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed