Authorization for WIA to Disclose PHI

Patient's name*

First NameMiddle (Optional)Last Name

Who are you authorizing to receive your Protected Health Information (PHI)?
(Please allow 48 hours for this request to be processed)

Individual/Entity*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of PHI to be disclosed (enter the dates of the specific information you want to be released)

Mammogram and breast sonogram/ultrasound images and/or reports

Other sonogram images and/or reports

DXA (bone density test) image and/or reports

Other (please specify)

Purpose of disclosure*

My insurance changed and I had to go elsewhereI movedI will be getting a breast MRI testI had an imaging test elsewhere and they need comparison studies

I would like my records to be:*

Held in the office for pick-upMailed (Records will be held in the office until $5.00 payment for postage is received via (1) check made payable to Weinstein Imaging Associates OR (2) phone call to our office to pay over the phone)Sent electronically (choose this option only if directed to do so by our staff, since this is possible with only certain facilities)

Date of pick up:

In which office were you last seen by us?*

North Hills (McCandless)ShadysideSouth Hills (Scott Twp)

Is this a permanent transfer of your records?*

YesNo

This authorization will expire at the end of the current calendar year, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration date to continue the authorization.

Date of expiration, if earlier than the end of the current calendar year:

You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice; this does not apply, however, to information already released. Also, this practice places no condition to sign this authorization on the delivery of healthcare/treatment.
We have no control over the individual(s)/entity you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of this practice.
If a CD/films are given to you personally, you must, by state law, maintain these records and make them available for medical and/or other purposes for a period of at least seven years. This responsibility is not relieved by transferring the CD/films to an individual or entity. Please note that CD/films are often lost if they are loaned to others.

I authorize Weinstein Imaging Associates to disclose or provide the above protected health information (PHI) about me to the individual/entity identified above.

By submitting the information below, you are electronically signing this form.

Patient's name*

Patient's birth date*

Last 4 digits of patient's Social Security #*

Your name and relationship, if you are the patient's personal representative

Your daytime phone*

Authorization to Disclose Protected Health Information