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Full Table of Contents
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Abbreviated
Table of Contents
Home Page
Patient Safety
Silence vs
Safety
Silenced
White wall
of Silence
Silencing
Conflict Of
Interest
Psychology of
Providers
Subjectivity
Blacklisting
Nurse survey
Loyalty
Mobbing and
bullying
Trust Us
Defensive
documenting
Report Rate
Risk
managemnt
SOAP
Management
Hospitals
Crime in
medicine
Sexual Abuse
Liability
Limitations
Free Speech
for Patients
Exploitation
OSMB Medical
Boards
Mammography
solutions
Medical errors
Medical
Complaints
One number
Links
Injured patients who want to help and be heard,
click here.
Thomas Jefferson said that given the choice between
government without newspapers and newspapers without government, he would choose
to have newspapers.
In medicine we have government without newspapers. Patients
cannot find out what they need to know to make informed choices. No one in
medicine records or reports the information patients need to know the most. So
patients will have to.
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RELEASE OF MEDICAL INFORMATION
I, __________________________________, hereby authorize
___________________________________
(patient)
______________________________________________________________________________________
(address)
to release copies of medical records and other information concerning my
diagnosis and treatment, including but not limited to information concerning
treatment of drug or alcohol abuse, alcoholism, drug related conditions, HIV
testing or treatment of HIV related conditions, psychiatric/psychological
conditions. Review of records is also authorized.
The following information may be released or reviewed:
- ( ) Case Summary
( ) Lab Work
- ( ) Doctors Orders and Progress Notes
( ) X-ray Reports & Other Testing
- ( ) Immunization Records
( ) Chart problem list
- ( ) History and Physical Exam
( ) Consultations
- ( ) Other _______________________________________________________
The above information is to be released to:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Purpose For Disclosure:
____________________________________________________________
REDISCLOSURE IS PROHIBITED WITHOUT SPECIFIC CONSENT OF THE
PERSON TO WHOM IT PERTAINS.
This statement must be signed and dated and may
be revoked at any time to the extent action has been taken prior to revocation.
This consent will expire sixty (60) days after the date below, or sooner by
choice, in which case this consent will expire on
_______________________________.
_____________________________________
________________________________________
Patient’s Name
Signature of Patient
______________________________________
_______________________________________
Address
Other person legally authorized to give consent
______________________________________
_______________________________________
Birth Date
Relationship to patient and reason
______________________________________
_______________________________________
Witness
Today’s Date
This information is being disclosed to the above individual/organization for
the above stated purpose from records whose confidentiality may be protected by
Federal Law.
Revised 4/99
Form #604
The form is intended to be a single page.
Nothing below here needs to be attached to your release.
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