|Copy Medical Records||For a patient's request to copy medical records located in the Health Information Management department. Instructions and additional information can be found here. Does not include authorization to copy/disclose mental health records.|
|Mental Health Records||Authorizes UCMC to disclose mental health information. Instructions can be found here.|
|General Authorization - Use and Disclose Health Information||General patient authorization to use and disclose PHI. (En Espanol)|
|Disclose to University of Chicago Administration||Allows UCMC to disclose health information of University of Chicago students to the UofC Dean on Call, Dean's Office, and/or UofC Housing Department for assisting with care at UCMC or assisting with transition back to campus, classes, relevant community services and UofC housing.|
|Trusted Requestor (Request for PHI for Uses Other Than Treatment or Payment)||Use this form when requesting PHI for uses other than treatment or payment.|
|Fax Cover Sheet||Includes
approved language for fax cover sheets.
|Notice of Privacy Practices Acknowledgement Form||Use this form when a
patient is given a Notice of Privacy Practices.
Collect the signed Acknowledgement Form from the
patient and forward to Health Information Management
(Medical Records), AMB WB20 (MC 0978).
|Billing Information||Use this form when the
patient or the patient's representative requests over
the telephone that the billing information be sent to
the address on record.
|Disclosure to University of Chicago||Used by UCMC patients
to assist with the process of obtaining their medical
records from non-UCMC providers.
|Education||Allows the UC
Organizations to use and disclose the health
information listed below for the following purpose(s):
create and present one or more case study(ies) about
individual's health information, create and present
one or more presentation(s) that includes individual's
health information, create and publish one or more
article(s) or other writing(s), and other purposes
that the user can list.
of the estate of the Patient named allows the UC
Organizations to disclose the Patient's health
||Allows the UC
Organizations to disclose the health information
listed for the purpose of allowing a particular
individual to observe clinical care in process. This
person is NOT a student in an educational program
sponsored by any UC Organization.
||Authorizes the UC OHCA
to disclose child's/ward's health information to
his/her school. (En
||Allows the UC
Organizations to disclose the health information for
the following purposes: confirm the need for leave of
absence, determination of disability, or other
identified by the user.
||Used by UC when having
difficulty with patient's insurance company paying the
bill for services rendered. UC finds that a patient's
employee benefits office can assist in working with
the insurance company. This form permits UC to share
the protected health information to the employee
department of the employer who provides patient health
||This allows the UC
Organizations to disclose health information for the
following purpose(s): confirm the need for leave of
absence, probable cause for drug/alcohol abuse,
pre-employment evaluation/screening, worker's
compensation evaluation and follow up treatment,
confirm fitness for duty/modified duty.
Members - FMLA
member is seeking Family and Medical Leave Act leave
("FMLA") and his/her employer has asked UCMC complete
an FMLA form. This form authorizes UCMC to complete
the FMLA form and give it to individual's family
member or send it to his/her employer.
||This allows the UC
Organizations to disclose PHI for Worker's
compensation review and claim processing and
adjudication, or other purpose identified by the user.
Enforcement Request for PHI
Police Department's Request Form for PHI.
Enforcement - Verification About Patient-Victim
this form to document law enforcement's immediate need
of information about a patient-victim. This form
is to be completed by any physician/licensed healthcare
provider treating the patient.