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Copy of Medical Records_91227237_59102702pdf
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 1.  
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     General Authorization to Use or Disclose Health Information Mercy
     Fitzgerald Hospital Nazareth Hospital Saint Francis Hospital St. Mary
     Medical Center Patient Name: DOB: SS# (last 4 digits): Med Recd #: Address:
     City/State/ZIP: Phone #: 1. The following individual(s) or organization(s)
     are authorized to make the disclosure:2. The type of information to be used
     or disclosed is as follows:Date(s) of Service: Face Sheet/Registration
     Sheet Progress Notes EKG/Cardiology Testing Results Discharge Summary
     Operative ReportRadiology Results: ER Record Pathology Report On CD On film
     On paper H&P Medication List Discharge Instructions Consults Lab Results
     Home Care RecordsBehavioral Health InformationInitial Entire Record
     Substance Abuse Information Initial OTHER: please specify Human
     Immunodeficiency Virus (HIV) Information InitialInformation related to
     treatment for AIDS/HIV, mental health care, or genetic information will not
     be disclosed unless specifically checked above.3. If my authorization
     includes HIV, Psychiatric/Mental Health, or Drug and Alcohol abuse
     (substance abuse) information, it may include; (i)information concerning
     whether an individual has been the subject of an human immunodeficiency
     virus (HIV) related test, has HIV, an HIVrelated illness, acquired
     immunodeficiency syndrome (AIDS), and/or information pertaining to the
     individual’s contact (Section 7100.133); (ii)substance abuse information in
     my health record may include whether or not I am receiving treatment, my
     prognosis, a brief description of myprogress, and/or a short statement as
     to whether I have relapsed into substance abuse and the frequency of such
     relapse (Pennsylvania Drugand Alcohol Abuse Control Act -1972 - Act 148
     section 7(e); (iii) behavioral health information services. (Mental Health
     Procedures Act 1976,section 5100.3-39).4. The information identified above
     may be used by or disclosed to the following individual or
     organization(s):Name: Fax:Address:5. This information for which I’m
     authorizing disclosure will be used for the following purpose: Sharing with
     other health care providers Personal use by patient Legal Other (please
     describe): 6.Format Requested (Check only one option): Deliver to
     MyChart/Patient Portal CD Paper Inspect a copy Email (if you choose email,
     insert email address and choose secured or unsecured below.)
     Secured/encrypted email (access instructions provided)
     Unsecured/unencrypted email**If you checked “unsecured email” please be
     aware that sending and receiving your medical record info via unsecured
     email createspersonal risk of interception and potential identity
     theft.*Please initial if you are requesting unsecured delivery via your
     personal email listed above. Initial**If records are unable to be emailed
     due to size limitations, please select an alternate format: CD
     Paper**Records provided on CD or Paper will be sent via the United States
     Postal Service.7. This authorization will begin on the date signed below
     and expire on:. If no expiration date is specified, this authorization will
     expire one year from the signature date.8. I hereby authorize the noted
     health care facility to use or disclosure the health information as
     described above. I understand that I may revokethis authorization at any
     time by sending a written request to the Health Information Management
     Department. I understand that the revocationwill not apply to information
     that has already been released in response to this authorization. I
     understand that the revocation will not apply tomy insurance company when
     the law provides my insurer with the right to contest a claim under my
     policy. An oral request for revocation canbe accepted in special
     circumstances.9. With the exception of AIDS/HIV, Behavioral/Mental Health,
     and Genetic Information, once your health information is disclosed, it may
     bere-disclosed by the recipient and may no longer be subject to state or
     federal law protections. Any information disclosed containing AIDS/HIV,
     Behavioral/Mental Health, and Genetic Information is protected under State
     regulations limiting the recipient’s right to make any furtherdisclosure of
     this information without prior written consent of the person to whom it
     pertains.Vivian Katsock4/7/19402215 Yardley RoadYardey, PA,
     1906777228576027/27/2020 - 10/30/2024✔Kristin Katsock1000 Brickell Plaza,
     Miami, FL, 33131✔✔10/30/2025katsock.k@gmail.com
     
 3.  
     10. I understand authorizing the use or disclosure of the information
     identified above is voluntary. I need not sign this form to ensure
     healthcaretreatment.Signature of patient or Personal Representative
     DateRelationship to patient, if signed by Personal RepresentativeSignature
     of witness Date Accept Refuse Yes No Yes (print email below)I have been
     offered a copy of this Authorization Form Patient (or agent/representative)
     identification verified I would like to receive the records requested in
     electronic format Email (if applicable): 10-30-2024Legal Representative
     (Executor, Patient Rep., HCPOA, etc.)katsock.k@gmail.com
     
 4.  
     REQUEST CONFIRMATIONPATIENT INFORMATIONFIRST NAME:VivianLAST
     NAME:KatsockDATE OF BIRTH:04/07/1940EMAIL
     ADDRESS:katsock.k@gmail.comVerifiedPHONE NUMBER:7722857602VerifiedMAILING
     ADDRESS:2215 Yardley Road Yardey PA 19067REQUEST INFORMATIONDATE
     REQUESTED:10/30/2024REASON FOR REQUEST:Not MentionedTERMS AND
     CONDITIONS:AcceptedCONSENT TO ANUNENCRYPTED EMAIL COPY:Not
     AcceptedNOTE:Time Sensitive - 11/06/2024IDENTITY VERIFICATION
     DOCUMENTS:executed POA.pdfDRIVING LICENSE OR GOVERNMENT ISSUED PHOTO
     ID:Powered ByFor assistance, please call (610)994-7500 Option 1 M-F from
     8:30 AM to 8:00 PM EST
     
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