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    Patient Access Request - Costco

    Uploaded by

    corey Sgars
    This document is an authorization form for Costco Health Centers to release a patient's protected health information. It requests the patient's name, date of birth, Costco membership number if applicable, address, and relationship if the request is coming from an authorized representative. The patient can authorize the release of their information to themselves or another party and can specify which Costco Health Center and what specific medical records or entire record to release. The authorization includes understandings that it can be revoked, may expire after one year, and includes rules around substance abuse, mental health, and HIV/AIDS records.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Patient Access Request - Costco

    Uploaded by

    corey Sgars
    56 views1 page
    This document is an authorization form for Costco Health Centers to release a patient's protected health information. It requests the patient's name, date of birth, Costco membership number if applicable, address, and relationship if the request is coming from an authorized representative. The patient can authorize the release of their information to themselves or another party and can specify which Costco Health Center and what specific medical records or entire record to release. The authorization includes understandings that it can be revoked, may expire after one year, and includes rules around substance abuse, mental health, and HIV/AIDS records.

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    This document is an authorization form for Costco Health Centers to release a patient's protected health information. It requests the patient's name, date of birth, Costco membership number if applicable, address, and relationship if the request is coming from an authorized representative. The patient can authorize the release of their information to themselves or another party and can specify which Costco Health Center and what specific medical records or entire record to release. The authorization includes understandings that it can be revoked, may expire after one year, and includes rules around substance abuse, mental health, and HIV/AIDS records.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    56 views1 page

    Patient Access Request - Costco

    Uploaded by

    corey Sgars
    This document is an authorization form for Costco Health Centers to release a patient's protected health information. It requests the patient's name, date of birth, Costco membership number if applicable, address, and relationship if the request is coming from an authorized representative. The patient can authorize the release of their information to themselves or another party and can specify which Costco Health Center and what specific medical records or entire record to release. The authorization includes understandings that it can be revoked, may expire after one year, and includes rules around substance abuse, mental health, and HIV/AIDS records.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    COSTCO HEALTH CENTERS AUTHORIZATION FOR RELEASE OF

    PROTECTED HEALTH INFORMATION

    Please provide the information below. We cannot respond to your request without this information.

    Patient Name: Date of Birth:

    Costco membership # (if applicable): Relationship:


    Patient Address:
    I, or my authorized representative, request that health information regarding my care and treatment be released
    as set forth below:

     Costco Pharmacy  Costco Optical  Costco Hearing Aid Center


    (Check the applicable Costco Health Center)

    Name and address of person or entity to whom information may be released:

    Send to patient directly

    Send to patient directly

    Send to patient directly

    Send to patient directly

    Reason for disclosure:  Request of individual  Other:


    Specific information to be released:  Entire Medical Record
     Medical Records from (date) to (date)
    Understandings:
     This authorization may be revoked in writing at any time, except to the extent that disclosure of
    information has already occurred prior to the receipt of revocation.
     Unless otherwise revoked, this authorization will expire on the following date, event or condition:
    ____________. If no expiration date, event or condition is noted, this authorization will expire one (1)
    year from the date of signing.
     This authorization may include disclosure of information relating to alcohol/drug abuse, mental health
    treatment , STD or HIV/AIDS related treatment only if I place my initial on the appropriate line below:
    X Alcohol/Drug Treatment x Mental Health Treatment
    STD Treatment HIV/AIDS
     I understand that a photocopy of this authorization shall be considered as effective and valid as the
    original.
     I understand that the information used or disclosed pursuant to this authorization may be subject to re-
    disclosure by the recipient and may no longer be protected by Federal Law.
     I understand that I am signing this authorization voluntarily and that treatment, payment, enrollment, or
    eligibility for benefits may not be conditioned upon my authorization of this disclosure.

    Patient Signature: Date:


    Personal Representative Signature*: Date:
    *If you are making this request on behalf of another individual, evidence of your personal representative status
    must be provided to the Costco Health Centers.

    Costco Wholesale Corporation


    Attn: Privacy Office • 999 Lake Drive • Issaquah, WA 98027 • [email protected]
    Phone 425-313-8347 • Fax 425-313-2822

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