To request a copy of your medical records: 1. 2. 3. 4. Fill out an Authorization To Release Copies of Medical Records. Fill out the Medical Records Request Questionnaire. Attach a copy of a picture ID. Mail all these materials to: For Norton Hospital, Kosair Children’s Hospital and Norton Healthcare Pavilion: Norton Health Information Management Attn: Midwest Copy Service P.O. Box 35070 Louisville, KY 40232-5070 For Norton Audubon Hospital: Norton Audubon Hospital Health Information Management One Audubon Plaza Drive Louisville, KY 40217 For Norton Southwest Hospital: Norton Southwest Hospital Health Information Management 9820 Third Street Road Louisville, KY 40272 For Norton Suburban Hospital: Norton Suburban Hospital Health Information Management 4001 Dutchman’s Lane Louisville, KY 40207
Record copy release form please complete and return to: NORTON HOSPITAL/KOSAIR CHILDREN’S HOSPITAL P.O. BOX 35070 Louisville, KY 40232-5070 (502) 629-8700 I HEREBY REQUEST A COPY OF THE FOLLOWING PATIENT’S MEDICAL RECORD: Full Name of Patient: _____________________________________________________________________________ Maiden Name/Alias: _____________________________________________________________________________ Patient’s Birth date: _______________________ MR# _________________________________________________ INFORMATION REQUESTED (X): ( ) Discharge Summary ( ) Emergency Room ( ) History & Physical ( ) Laboratory Results ( ) Operative Reports ( ) X-Ray Results OR date(s)____________________ ( ) Orders ( ) Progress Notes ( ) Nurses Notes ( ) Psychotherapy Notes ( ) Other (Specify)____________________________________________________________________ IDENTIFY THE HOSPITAL WHERE THE PATIENT WAS TREATED AND THE SPECIFIC YEAR OF TREATMENT Norton Hospital (DOWNTOWN) Kosair Children’s Hospital Norton Healthcare Pavilion Norton Audubon Hospital Norton Carroll County Hospital Norton Southwest Hospital Norton Spring View Norton Suburban Hospital Year ____________ THE ABOVE RECORD IS TO BE RELEASED TO THE FOLLOWING INDIVIDUAL: Name & Title: _____________________________________________________________ Street Address: ____________________________________________________________ City/State/Zip: _____________________________________________________________ Phone Number: ____________________________________________________________ THIS RECORD IS REQUESTED FOR THE FOLLOWING REASON (X): ( ) Continued Medical Care ( ) Legal Purposes ( ) Personal Interest ( ) Insurance Purposes ( ) Other (Specify)_______________________________________________________ The authorization must be signed and dated and may be revoked in writing at any time except to the extent action has been taken prior to revocation. This consent will expire 60 days after the date below or sooner by my choice, in which case this . I will hereby state that I have read and fully understand the above consent will expire on statements as they apply to me. I hereby consent to the disclosure of the medical records to the purpose and extent stated above. REQUEST FOR RECORD COPY RELEASE WILL BE HANDLED ON A FIRST COME, FIRST SERVE BASIS. ( ) Kentucky Law directs health care ( ) Additional requests for copies will providers to furnish to a patient, be charged a rate of $1.00 per page. at the patient’s request, one free copy of the patient’s Medical Record. I UNDERSTAND THAT IF THE PERSON OR ENTITY THAT RECEIVES THE INFORMATION IS NOT A HEALTH CARE PROVIDER OR HEALTH PLAN COVERED BY FEDERAL PRIVACY REGULATIONS, THE INFORMATION DESCRIBED ABOVE MAY BE REDISCLOSED AND NO LONGER PROTECTED BY THESE REGULATIONS. I HEREBY AFFIRM THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE STATEMENTS AND CONSENT TO THE DISCLOSURE OF THE MEDICAL RECORD FOR THE PURPOSE AND EXTENT STATED ABOVE. RELEASE OF INFORMATION FORM MUST HAVE A COPY OF PICTURE ID ATTACHED. IF NORTON HEALTHCARE IS ASKING TO USE/DISCLOSE MY INFORMATION, I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION AND THAT MY REFUSAL TO SIGN WILL NOT AFFECT MY ABILITY TO OBTAIN TREATMENT OR PAYMENT OR MY ELIGIBILITY FOR BENEFITS. I MAY INSPECT OR COPY ANY INFORMATION USED/DISCLOSED UNDER THIS AUTHORIZATION. (NOTE: THIS ITEM IS NOT REQUIRED IF THE DISCLOSURE IS REQUESTED BY THE PATIENT.)
PATIENT’S SIGNATURE, OR ________________________________________________DATE__________________________ PARENT OR LEGAL GUARDIAN’S SIGNATURE ______________________________________________________________ RELATIONSHIP TO PATIENT_____________________________ SOCIAL SECURITY NUMBER ____________________________ CONTACT PHONE NUMBER________________________ PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentially is protected by federal and/or state law. Federal and state regulations prohibits you (the recipient) from making any further disclosure without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
Medical Records Request Questionnaire Request for Medical Record of Minor Patient: Authorization for the release of medical records must be provided by the parent or legal guardian of the minor patient. If the parents are divorced, the custodial parent must authorize the release of medical records. If the parents have joint custody of the minor patient, then either parent may authorize the release of medical records. Check One: Parent If parents are divorced or if a court has entered a custody order for minor patient, please check one. Sole Custody; Enter Name of Custodial Parent Joint Custody Legal Guardian A Legal Guardian must present an order of appointment, signed by a judge, granting to him/her guardianship of the minor patient. Requests for Medical Record of Adult Patient: An adult, competent patient must authorize, in writing, the release of medical information to any third party. If you are requesting the medical record of an adult patient (not yourself), you must provide the following information: Please check one: Authorization Form signed by the patient. Authorization Form signed by the patient’s power of attorney (POA) and a copy of the POA document.
If the adult patient is deceased, Authorization Form signed by the executor or administrator of the patient’s estate and a copy of the qualification or order of appointment as the executor or administrator. If the estate was not probated, the medical record may be released to next-of-kin; please check one: Spouse Adult Child Parent Adult Sibling Adult Grandchild I hereby certify that the information stated above is true, accurate and complete. Date: Signature of Requesting Person