CMI Release of Patient Health Information (PHI)
I hereby authorize the use of disclosure of the individually identifiable health information as described below. I understand that if my health information is used or disclosed as I am requesting, the released information may no longer be protected by privacy regulations issued by the federal government.
CMI allows 10 days after the exam was performed for the ordering provider to review the results with you. After 10 days, CMI will release the information as requested. Please contact our office by phone, if you require an exception to this policy.
Phone: 315-792-4666, option 3
For CMI Office Use:
___ Released records as requested.
Request denied due to one of the following- please check all that apply.
___ Information was compile for civil, crimincal or administrative actions.
___ Was not created or performed by this practice.
___ Professional decision that this information may be harmful to the patient.
Authorizing signature:_______________________________ Date:___________
Records copied and sent (date/initials) __________ /_____
Request denial, patient notified by:_____________________ Date:__________
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