347274 MECH.indd PDF METHODIST JENNIE EDMUNDSON HOSPITAL. METHODIST

Methodist Hospital Foundation

03?/04?/2020 Methodist Physician's Clinic. Women's Center. Methodist Women's Hospital. Medical Office Bldg. 402-815-1813. Chaplain Melissa Strong.

methodist Womens Hospital & 717 medical Office Building

Methodist Physicians Clinic. Public Elevator/Stairway. Sta Only. Sta Elevator/Stairway. Imaging & Lab. Emergency. Women's Center. • OB/GYN Suites.

28330 MHS MPC Location Guide 2016 FINAL.indd

Methodist Physicians Clinic is proud to be recognized by the National. Committee for Quality Assurance (NCQA) as a Patient-Centered. Medical Home.

Methodist Hospital Foundation

30?/03?/2020 Methodist Physician's Clinic. Women's Center. Methodist Women's Hospital. Medical Office Bldg. 402-815-1813. Chaplain Melissa Strong.

347274 MECH.indd

METHODIST JENNIE EDMUNDSON HOSPITAL. METHODIST PHYSICIANS CLINIC. Patient Authorization for. Disclosure of Health Information.

Methodist Physicians Clinic

Methodist Physicians Clinic (MPC) is a multi-specialty ambulatory care organization under the Nebraska Methodist. Health System umbrella.

Untitled

Sutherland Cardiology Clinic. UT Methodist Physician Group. UT Methodist Physicians. UT Methodist Physicians. UT Methodist Physicians. UTMP.

VALVE CLINIC

seen at the Valve Clinic and valve disease patients from referring physicians outside Houston Methodist a multidisciplinary team of cardiovascular.

Application for Financial Assistance

Methodist Health System's financial assistance program drugs eyeglasses or other non-acute/non-physician health ... Methodist Physicians Clinic.

If your clinic is a Methodist Affiliate but is not named in this list

METHODIST HOSPITAL

METHODIST WOMEN'S HOSPITAL

METHODIST JENNIE EDMUNDSON HOSPITAL

METHODIST PHYSICIANS CLINIC

Patient Authorization for

Disclosure of Health Information

PERMANENT PART OF MEDICAL RECORD

Page 1 of 2

RELEASEOFINFO

Rev 07/2018

Patient Name: Date of Birth:

Address: City: State: Zip:

Phone: Previous/Maiden Name:

Recipient of my information Name:

Address: City: State: Zip:

Phone: Fax (healthcare provider only):

I request that Nebraska Methodist Health System (NMHS) or an affi liate release information to or

obtain from the facility below:The information to be disclosed relates to date(s) of care/treatment: OR Date Range: To From

The purpose of the disclosure:

Disclosure Format (Paper is default) Mail Fax E-mail (complete portal release) Electronic format (CD default)

By signing this Authorization form, I understand that:For Employees Only: Access to all NMHS electronic health records by Employed Family Member (view only)

I understand that the information in my health record may include information relating to alcohol, drug, or substance abuse, sexuallytransmitted disease, acquired immunodefi ciency syndrome (AIDS), human immunodefi ciency virus (HIV) or gene related impairmentsincluding genetic testing. You are authorized to release all information related to such diagnosis, testing and treatment unless specifi callyexcluded as set forth below:

Requests for copies of medical records are subject to reproduction fees in accordance with federal/state regulations.

I have the right to revoke this authorization at any time. Revocation must be made in writing and presented or mailed to the

Health Information Management Department at 8303 Dodge St. Omaha, NE 68114. Revocation will not apply to information

that has already been disclosed in response to this authorization.

Unless otherwise revoked, this authorization will expire one (1) year from the date signed below or upon the following date/event/condition: .

Treatment, payment, enrollment or eligibility for benefi ts may not be conditioned on whether I sign this authorization.

Any disclosure of information carries with it the potential for unauthorized re-disclosure and the information may not be protected

by federal confi dentiality rules.• •Records Released From:

Hospital Clinic Both

Request of Individual/personal

Referral to Specialist

Continuing CareChange of Doctor/Transfer of Care

Insurance -type:

Workers CompLegal

Other

Emergency Room Record

Complete Medical Record

Operative Report(s)

Abstract

(discharge summary, history andphysical, operative report(s), consultations and testresults)

Laboratory Reports

Radiology Reports

Radiology Images

Immunization RecordPhysician Offi ce Visits

Medication List

PT/OT

Other:All encounters/visits at Dr:

Patient or Authorized Representative Signature Printed Name Date

If applicable, please attach legal documentation if required, i.e. Power of Attorney, guardianship, personal representativeRelationship to patient is applicable

METHODIST HOSPITAL

METHODIST WOMEN'S HOSPITAL

METHODIST JENNIE EDMUNDSON HOSPITAL

METHODIST PHYSICIANS CLINIC

PERMANENT PART OF MEDICAL RECORD

Page 2 of 2

RELEASEOFINFO

Rev 07/2018

Date Rcd:

MRN: FIN#:

Printed By:

ID:Location:Pg. Count:Released By:Released Dt:

Methodist Physicians Clinic Release of Information10060 Regency Cir.Omaha, NE 68114Ph# 402-354-1494Fax# 402-354-1350roi@nmhs.org Hours of Operation Monday - Friday 8am-5pm Closed noon-1:00pm

Contact Information:

Nebraska Methodist Hospital

8303 Dodge St.

Omaha, NE 68114

Ph# 402-354-1460

Fax# 402-815-9163

nmhs.hospitalroi@nmhs.org

Hours of Operation Monday - Friday 8am-5pm

Methodist Jennie Edmundson

933 E. Pierce St.

Council Bluffs, IA

Ph# 402-354-1460

Fax# 402-815-9163

nmhs.hospitalroi@nmhs.org

Hours of Operation Monday - Friday 8am-4pm

For Offi ce Use Only

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[PDF] 347274 MECH.indd METHODIST JENNIE EDMUNDSON HOSPITAL. METHODIST

METHODIST HOSPITAL

METHODIST WOMEN'S HOSPITAL

METHODIST JENNIE EDMUNDSON HOSPITAL

METHODIST PHYSICIANS CLINIC

Patient Authorization for

Disclosure of Health Information

PERMANENT PART OF MEDICAL RECORD

Page 1 of 2

RELEASEOFINFO

Rev 07/2018

Patient Name: Date of Birth:

Recipient of my information Name:

The purpose of the disclosure:

Hospital Clinic Both

Request of Individual/personal

Referral to Specialist

Continuing CareChange of Doctor/Transfer of Care

Insurance -type:

Workers CompLegal

Emergency Room Record

Complete Medical Record

Operative Report(s)

Abstract

Laboratory Reports

Radiology Reports

Radiology Images

Immunization RecordPhysician Offi ce Visits

Medication List

Other:All encounters/visits at Dr:

METHODIST HOSPITAL

METHODIST WOMEN'S HOSPITAL

METHODIST JENNIE EDMUNDSON HOSPITAL

METHODIST PHYSICIANS CLINIC

PERMANENT PART OF MEDICAL RECORD

Page 2 of 2

RELEASEOFINFO

Rev 07/2018

Date Rcd:

Printed By:

ID:Location:Pg. Count:Released By:Released Dt:

Contact Information:

Nebraska Methodist Hospital

8303 Dodge St.

Omaha, NE 68114

Ph# 402-354-1460

Fax# 402-815-9163

Hours of Operation Monday - Friday 8am-5pm

Methodist Jennie Edmundson

933 E. Pierce St.

Council Bluffs, IA

Ph# 402-354-1460

Fax# 402-815-9163

Hours of Operation Monday - Friday 8am-4pm

For Offi ce Use Only