Nationwide Children's Hospital Protected Health Information Request Form
This document is used to request access to and copies of protected health information at Nationwide Children's Hospital. Each section must be completed entirely to avoid processing delays. Sensitive information requests require additional authorization.
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How do I fill this out?
Complete the form by filling in the patient's information, the access method, requested information, and any sensitive information needed. Ensure all fields are filled out accurately to avoid delays. More detailed instructions are provided below.
How to fill out the Nationwide Children's Hospital Protected Health Information Request Form?
1
Fill in the patient’s full name, date of birth, and contact information.
2
Specify the access method and format for the requested information.
3
Indicate the type of health information needed by selecting the appropriate options.
4
Mention any sensitive information if applicable, using the checkboxes provided.
5
Provide payment details and submit the completed form via mail, email, or fax.
Who needs the Nationwide Children's Hospital Protected Health Information Request Form?
1
Patients who require their medical records for personal use or ongoing care.
2
Legal representatives needing access to a patient's health information.
3
Insurance companies requesting detailed medical records for claims processing.
4
Healthcare providers needing a patient’s prior health records for continued treatment.
5
Researchers seeking specific health data for academic studies and publications.
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1
Upload the PDF to PrintFriendly’s editor.
2
Use the text tool to fill in required fields such as patient information and access method.
3
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4
Review the completed document for accuracy and completeness.
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What are the instructions for submitting this form?
Submit the completed form using one of the following methods: By Mail: Nationwide Children's Hospital, Attn: HIM Dept., 700 Children's Drive, Columbus, Ohio 43205 By Email: MedicalRecordRequests@nationwidechildrens.org By Fax: Health Information Management at 614-355-0797 Advice: Ensure all sections are thoroughly completed to avoid delays in processing. Double-check sensitive information and required authorizations before submission to ensure compliance.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this form in 2024 and 2025. Please ensure it is submitted as soon as possible to avoid delays.
What is the purpose of this form?
The purpose of this form is to allow patients or their personal representatives to request access to and copies of individual identifiable health information. By completing this form, individuals can specify the format and delivery method for the requested information. This ensures that patients have access to their medical records for ongoing care, legal purposes, or personal use. Nationwide Children’s Hospital uses this form to process requests in compliance with federal and state regulations, ensuring the proper handling and protection of sensitive health information. Patients can request various types of records, including inpatient and outpatient records, immunizations, and specific test results. Sensitive information, such as substance abuse and mental health records, requires additional authorization to be released. Timely access to health information is vital for effective patient care, legal matters, and personal record keeping. By providing a clear and structured request process, Nationwide Children’s Hospital facilitates the secure transfer of health information to authorized individuals. Completing this form accurately and entirely is crucial to avoid delays and ensure the patient's needs are met efficiently.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Includes fields for last name, first name, middle name, date of birth, address, phone number, and other possible names.
- 2. Access Method: Fields to specify the access method and format for the requested information.
- 3. Information Requested: Options to specify the type of information needed, including date ranges and specific record types.
- 4. Sensitive Information: Checkboxes for requesting access to sensitive information like substance abuse, HIV-related information, and mental health records.
- 5. Payment Information: Instructions on how to pay for a copy of the records, including options for debit or credit card, cashier’s check, or money order.
- 6. Submission Instructions: Details on how to submit the completed form via mail, email, or fax.
- 7. Signature and Verification: Fields for the patient or personal representative's signature and verification of identity.
What happens if I fail to submit this form?
Failing to submit this form will result in not receiving the requested health information. This could impact ongoing patient care, legal proceedings, or personal recordkeeping.
- Delay in Receiving Health Information: Your medical records will not be processed and provided on time.
- Impact on Medical Treatment: Healthcare providers may not have access to necessary information for ongoing treatment.
- Legal Consequences: Important health information needed for legal purposes will not be available.
- Personal Records Incomplete: Your personal records will lack important medical history and details.
How do I know when to use this form?
- 1. Access Personal Medical Records: Request your health information for personal use and recordkeeping.
- 2. Ongoing Healthcare Needs: Provide your new healthcare providers with copies of your medical history.
- 3. Legal Proceedings: Obtain necessary health information for legal cases or discussions.
- 4. Insurance Claims: Supply your insurance with medical records for claim processing.
- 5. Research Purposes: If applicable, provide health records for academic or medical research.
Frequently Asked Question
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Upload the PDF to PrintFriendly, use the editor to fill in the fields, and save your changes.
Can I sign the PDF?
Yes, use PrintFriendly's signing tool to add your digital signature.
How can I share the completed document?
Choose the share option to email the document, upload to cloud storage, or generate a link.
What formats can I request health information in?
You can request information in formats such as CD, thumb drive, paper, or electronically.
Are there any fees for obtaining my health records?
Yes, there is a flat fee of $6.50 for copies of medical records.
How long does it take to process the request?
Processing times may vary, but you will be notified if it takes longer than 30 days.
Can I request sensitive information?
Yes, but additional authorization may be required for sensitive information.
How do I submit the completed form?
You can submit it by mail, email, or fax using the provided contact details.
Can I request information for a specific date range?
Yes, you can specify the date range for the information you need.
Is a photocopy of the form valid?
Yes, a photocopy of the form is considered as valid as the original.
