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Blank Memorial Hermann Release PDF Form

The Memorial Hermann Release form is a document that allows patients to authorize the release of their medical records from Memorial Hermann Health System. This form is essential for ensuring that healthcare providers can share necessary information for medical care, legal matters, or insurance purposes. To get started, fill out the form by clicking the button below.

Article Guide

The Memorial Hermann Release form is a crucial document for patients seeking to manage their medical records and ensure their health information is shared appropriately. This form facilitates the release of protected health information from various facilities within the Memorial Hermann Health System, including hospitals and outpatient centers. Patients can specify which records they wish to access, including lab results, progress notes, and more. Additionally, the form allows individuals to choose how they want their records delivered—whether in paper format or electronically. It’s important for patients to indicate the dates of service they wish to include and the purpose of the request, whether it be for medical care, legal reasons, or insurance purposes. The authorization remains valid for 180 days after signing, ensuring that patients have ample time to manage their records. Furthermore, the form includes a disclaimer about the potential risks of re-disclosure, emphasizing the need for careful consideration when sharing sensitive information. By signing this document, patients also release Memorial Hermann from liability regarding the lawful release of their health information, thereby ensuring a smooth process in obtaining necessary medical documentation.

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One mailing address for all facilities (not a physical address):
Memorial Hermann Release of Information
7737 SWF C94 Houston. TX 77074		 Inspection  Amendment Of Protected Health Information
Authorization for:  Disclosure		 Inspection  Amendment Of Protected Health Information
Patient Name				Date of Birth		Medical Records#

Address						Telephone #
						(	)
I hereby authorize Memorial Hermann Health System to release my records from the following facilities
(please check ONLY facilities that apply):
HOSPITALS:
 Memorial City	 NW/Greater Heights		 Southwest		 Northeast		 Sugar Land
 Hermann-TMC	 Katy		 Woodlands		 Southeast		 TIRR
 MHOSH	 Cypress		 Pearland		 Katy Rehab
OUTPATIENT CENTERS:
 River Oaks	 Outpatient Imaging Center		 Sport Medicine/Physical Therapy		 Medical Group
 Katy	 Convenient Care Center		 PhyTex/Mischer Assoc.		 Home Health		 Physicians at Sugar Creek

RELEASE TO: Please provide Name/Address of person/organization to which disclosure is to be made

__________________________________________________________________________________________________________________________

Phone # ___________________________________________________ Fax# _______________________________________________________

DATES OF SERVICE to be released: _________________________________________________________________________________________

		Specify dates - this line MUST BE completed
For the following purpose:  Medical Care	 Legal	 Insurance	 Other (detail below)

__________________________________________________________________________________________________________________________

COPY MY MEDICAL RECORDS TO: please check one  PAPER OR  Electronic Disclosure such as CD

Select Portions of Protected Health Information MHHS is authorized to release

 Abstract/Pertinent Information
 Lab	 ENTIRE RECORD INCLUDING - HIV TESTING ONLY
 Emergency Room
 Radiology Reports	 EXCLUSIONS
 Admit/Discharge Summary	_____________________________________________________________
 MD Progress Notes
 H&P	_____________________________________________________________
 Cardiac Studies	 Radiology Digital Images
 Consultation Report	 Itemized Bill
 Face Sheet	 CPT Codes
 Operative/Procedure Report	 Other _______________________________________________________

This authorization is valid until the 180th day after the date it is signed unless it provides otherwise, not to exceed 24 months, or

unless it is revoked, and covers only treatment(s) for the dates specified above.

I, the undersigned, have read the above and authorize the staff of Memorial Hermann Health System to disclose such information as herein contained. I have the right to revoke this authorization in writing at any time except to the extend that action has been taken in reliance upon it. I understand that when this information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected. I hereby release and hold harmless the above named facility and its parent company from all liability and damages resulting from the lawful release of my Protected Health In formation.

______________________	___________________________________________________________	____________________________________
Date	Signature of Patient/Parent/Conservator/Guardian	Authority/Relationship to Patients

Fees/charges will comply with all laws and regulations applicable to release of Protected Health Information. Records will be released after full payment has been received.

Release of Protected

Health Information

73115 (10/17)

➤ PDF File

Form Specifications

Fact Name	Description
Mailing Address	The release form must be sent to Memorial Hermann Release of Information, 7737 SWF C94, Houston, TX 77074.
Purpose of Release	Patients can authorize the release of their medical records for various purposes, including medical care, legal matters, and insurance.
Valid Duration	This authorization is valid for 180 days from the date it is signed, not exceeding 24 months unless revoked earlier.
Facility Selection	Patients must select the specific Memorial Hermann facilities from which they want their records released, including hospitals and outpatient centers.
Disclosure Method	Records can be disclosed in paper format or electronically, such as on a CD, based on patient preference.
Patient Rights	Patients have the right to revoke their authorization in writing at any time, except where actions have already been taken based on the authorization.
Fees and Charges	All fees related to the release of Protected Health Information will comply with applicable laws and regulations.
Governing Law	This form is governed by Texas state laws regarding the release of medical records and patient information.

Memorial Hermann Release: Usage Guidelines

Completing the Memorial Hermann Release form is a straightforward process. This form is essential for authorizing the release of your medical records to a specified individual or organization. Following the steps outlined below will ensure that all necessary information is provided accurately.

Begin by entering your Patient Name and Date of Birth in the designated fields.
Fill in your Medical Records Number, if known, followed by your Address and Telephone Number.
Check the appropriate boxes to indicate whether you are requesting Inspection or Amendment of Protected Health Information.
Select the facilities from which you want your records released by checking the corresponding boxes under HOSPITALS and OUTPATIENT CENTERS.
In the RELEASE TO section, provide the name and address of the person or organization to whom the records will be sent.
Enter the Phone Number and Fax Number of the recipient, if applicable.
Specify the DATES OF SERVICE that you want to be included in the release.
Indicate the purpose for the request by checking one of the options: Medical Care, Legal, Insurance, or Other and provide details if necessary.
Choose whether you want your medical records to be copied to PAPER or Electronic Disclosure such as CD.
Select the portions of your protected health information that you authorize to be released by checking the relevant boxes.
Read the authorization statement carefully. Sign and date the form in the appropriate fields.
If applicable, provide your authority or relationship to the patient in the designated area.

Your Questions, Answered

What is the purpose of the Memorial Hermann Release form?

The Memorial Hermann Release form is designed to authorize the release of your protected health information. This includes medical records from various facilities within the Memorial Hermann Health System. By completing this form, you allow designated individuals or organizations to access your medical information for specific purposes, such as medical care, legal matters, or insurance claims. It is essential to specify the dates of service and the type of information you wish to be disclosed to ensure that your request is processed accurately.

How do I complete the Memorial Hermann Release form?

To complete the Memorial Hermann Release form, begin by providing your personal information, including your name, date of birth, and contact details. Next, indicate which facilities you are authorizing to release your records by checking the appropriate boxes. Specify the dates of service for which you want the records released and the purpose of the request. You will also need to choose whether you prefer to receive your medical records in paper or electronic format. Finally, sign and date the form, ensuring that you have read and understood the terms outlined in the authorization.

How long is the authorization valid?

The authorization granted by the Memorial Hermann Release form is valid for 180 days from the date it is signed. However, it cannot exceed a period of 24 months unless stated otherwise in the form. It is important to note that you have the right to revoke this authorization in writing at any time, except for actions already taken based on your consent. This ensures that you maintain control over your health information.

Are there any fees associated with obtaining my medical records?

Yes, there may be fees associated with the release of your medical records. These fees will comply with all applicable laws and regulations governing the release of protected health information. Records will only be released after full payment has been received. It is advisable to inquire about any potential charges before submitting your request to avoid unexpected costs.

Common mistakes

Incomplete Patient Information: Failing to provide all necessary details such as the patient's name, date of birth, and medical record number can delay the processing of the release.
Missing Facility Selection: Not checking the appropriate facilities from which records are to be released can lead to incomplete information being sent. Ensure you only select the facilities that apply.
Unspecified Dates of Service: Leaving the dates of service section blank is a common mistake. This line must be filled out to indicate which records are being requested.
Improper Recipient Information: Providing incorrect or incomplete information for the recipient of the records can result in delays or the records being sent to the wrong person or organization.

Documents used along the form

The Memorial Hermann Release form is essential for allowing the sharing of medical records. It is often accompanied by other documents that help clarify the process and ensure compliance with legal requirements. Below is a list of documents that are commonly used alongside the Memorial Hermann Release form.

Patient Consent Form: This document confirms that the patient agrees to the release of their medical information. It usually includes details about what information will be shared and with whom.
HIPAA Privacy Notice: A notice that informs patients of their rights under the Health Insurance Portability and Accountability Act (HIPAA). It explains how their medical information may be used and shared.
Authorization for Release of Medical Records: Similar to the Memorial Hermann Release form, this document allows patients to specify which records they want released and to whom.
Power of Attorney (POA): This legal document allows one person to act on behalf of another in legal or financial matters, including the release of medical records.
Advance Directive: A document that outlines a patient’s wishes regarding medical treatment in case they are unable to communicate their preferences. This may influence the type of information shared.
Medical Records Request Form: A form that patients or their representatives fill out to formally request copies of medical records from a healthcare provider.
Insurance Authorization Form: This document is often required by insurance companies to approve payment for medical services. It may involve sharing certain medical records.
Release of Information Log: A record-keeping document that tracks who has accessed a patient’s medical records and for what purpose, ensuring compliance with privacy laws.
Billing Statement: This document outlines charges for medical services and may include details about what records were used for billing purposes.
Referral Form: A form used when a patient is referred to another healthcare provider. It may include necessary medical history and records to ensure continuity of care.

These documents work together to facilitate the safe and legal sharing of medical information. Each plays a specific role in ensuring that patient rights are respected and that the process is smooth for all parties involved.

Similar forms

HIPAA Authorization Form: Like the Memorial Hermann Release form, this document allows individuals to authorize the release of their health information. It ensures that personal medical records are shared only with specified individuals or entities.
Patient Consent Form: This form is similar in that it requires a patient’s consent for treatment or sharing of information. It emphasizes the patient's right to control who accesses their medical data.
Medical Records Request Form: This document is used to formally request medical records. It serves a similar purpose by enabling patients to specify what records they need and to whom they should be sent.
Release of Information Authorization: This form is akin to the Memorial Hermann Release form, allowing patients to authorize the release of their medical information to third parties for various purposes, such as legal or insurance needs.
Informed Consent Form: This document is similar in that it requires patients to acknowledge understanding of the risks and benefits of a procedure or treatment, often including the sharing of relevant health information.
Disclosure Authorization Form: This form allows patients to specify which health information can be disclosed and to whom, mirroring the intent of the Memorial Hermann Release form.
Third-Party Release Form: This document permits the sharing of health information with a designated third party, similar to how the Memorial Hermann form allows for the release of information to specified individuals or organizations.
Patient Information Release Form: This form is used to grant permission for the release of a patient's medical information to another healthcare provider or entity, much like the Memorial Hermann Release form.

Dos and Don'ts

When filling out the Memorial Hermann Release form, it is essential to be thorough and careful. Here is a list of things you should and shouldn't do to ensure a smooth process.

Do read the entire form carefully before starting to fill it out.
Do provide accurate and complete information, including your name, date of birth, and contact details.
Do check only the facilities from which you want to release your records.
Do specify the dates of service clearly to avoid any confusion.
Don't leave any required fields blank; ensure all necessary sections are completed.
Don't forget to sign and date the form at the bottom to validate your request.
Don't submit the form without checking for any mistakes or omissions.
Don't assume that your request will be processed without full payment if applicable.

Misconceptions

Understanding the Memorial Hermann Release form is essential for patients navigating their healthcare information. However, several misconceptions can lead to confusion. Here are four common misunderstandings:

Misconception 1: The release form is only for hospitals.

This is not true. While the form does include various hospitals within the Memorial Hermann Health System, it also covers outpatient centers and other facilities. Patients can authorize the release of information from a wide range of locations, not just hospitals.

Misconception 2: The authorization is permanent.

Many believe that once they sign the release form, it remains in effect indefinitely. In reality, the authorization is valid for 180 days from the date of signing, unless specified otherwise. This means patients should be aware of the time frame when requesting their records.

Misconception 3: Patients can only receive their records in paper format.

Another common belief is that records can only be sent as physical copies. The form actually provides an option for electronic disclosure, such as receiving records on a CD. This flexibility allows patients to choose the method that best suits their needs.

Misconception 4: Signing the form means patients lose control over their information.

Some individuals worry that by signing the release form, they are relinquishing control over their medical information. However, patients retain the right to revoke their authorization at any time, except for actions already taken in reliance on the authorization. This ensures that patients can manage their health information actively.

Key takeaways

When filling out the Memorial Hermann Release form, consider the following key takeaways:

Single Mailing Address: All requests for information should be sent to the designated mailing address: Memorial Hermann Release of Information, 7737 SWF C94, Houston, TX 77074.
Specify Facilities: It is essential to check only the facilities from which you want records released. This ensures that the request is processed accurately and efficiently.
Complete All Required Information: Make sure to fill in all necessary details, such as patient name, date of birth, and dates of service. Incomplete forms may delay the release of your records.
Authorization Validity: The authorization remains valid for up to 180 days after signing, unless otherwise specified. This means you should ensure your request is made within this timeframe.