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When it comes to managing personal health information, one key document plays a vital role: the SL 0427 form, also known as the Authorization for Use and Disclosure of Protected Health Information (PHI). This form empowers individuals by allowing them to grant permission for St. Luke’s Hospital to share their medical records with specified persons or organizations. Key details required include the patient’s name, date of birth, and social security number, alongside a list of medical records to be disclosed, ranging from complete medical records to specific reports such as progress notes or laboratory results. Importantly, the form highlights sensitive information that may require added caution, such as data related to mental health, substance use, or HIV status. Furthermore, individuals retain the right to revoke their authorization and can inspect the information intended for disclosure. Notably, St. Luke’s Hospital emphasizes that signing the form is not a prerequisite for receiving treatment, thereby ensuring that patients' access to care remains unhindered. By understanding the nuances of the SL 0427 form, patients can make informed choices about their health information and navigate the complexities of medical privacy with confidence.

Sl 0427 Example

Patient Name:

 

 

 

 

 

 

 

 

Treatment Date:

 

 

 

 

 

 

Please print

 

 

 

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

Phone:

 

Purpose of Request:

 

 

 

 

 

 

 

 

 

 

 

 

 

I hereby authorize:

St. Luke’s Hosptial

 St. Luke’s Des Peres

 St. Luke’s Medical Group

 

 

 

 

Chesterfield, MO

Des Peres, MO

St. Louis, MO

To Release Record To:

 

 

 

 

 

To Obtain Record From (Provider Name):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

Street Address:

 

 

 

 

 

 

City, State, Zip:

 

 

 

 

 

 

City, State, Zip:

 

 

 

 

 

Phone:

 

Fax:

 

 

Phone:

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I specifically authorize the use and disclosure of the following:

Clinical Abstract

OR

Discharge Summary

ER Physician Note

includes all documents listed

 

History & Physical

Laboratory Reports

 

 

Consultation Reports

Radiology Reports

 

 

Operative Reports

Cardiology Reports

Other (please specify):

Complete Record (entire medical record including nursing notes and orders)

The information to be used or disclosed pursuant to this authorization may include information relating to: (1) AIDS or HIV infection; (2) treatment of drug or alcohol use; or (3) mental or behavioral health or psychiatric care; (4) sexually transmitted disease; or (5) genetic testing.

Except:

I may revoke this authorization in writing at any time. I understand that such revocation will not have any effect on the information already used or disclosed before receipt of my written notice of revocation. Unless earlier revoked, this authorization will expire one year from the date it was signed. I understand I may choose to restrict or extend the expiration date. I may request to inspect or copy the information to be disclosed. I may refuse to sign this authorization. I understand that I am not required to sign the authorization to receive treatment. Once release of this information is made to the above named person/organization, my information may be subject to re-disclosure by the recipient.

I may be charged fees for the copying of such information if I am requesting information for myself or for a third party. Such fees will comply with state and federal laws.

I have read the above information and authorize disclosure of the identified information to the person/organization and for the purpose described herein. I understand that, by signing this document, I release and discharge the disclosing entity

from any liability and will hold it harmless for any release made pursuant to the authorization.

Signature of Patient/Legal Guardian/Personal Representative

If someone signs on behalf of the patient, state your relationship to the patient

AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

Page 1 of 1

Date

Time

 

Time

Date

Authorization Expires:

(up to one year if not otherwise specified)

Form No. SL-0427

ROI CORRESPONDENCE TAB

Rev. 08/2019

Form Characteristics

Fact Name Details
Form Title Authorization for Use and Disclosure of Protected Health Information (PHI)
Governing Law This form is governed by the Health Insurance Portability and Accountability Act (HIPAA) regulations.
Patient Information Required The form requires the patient’s name, date of birth, and Social Security Number.
Purpose of Request Patients must specify the purpose for which they authorize the release of their medical records.
Types of Records Patients can authorize disclosure for complete medical records or specific types like discharge summaries and laboratory results.
Sensitive Information Informed consent is required for the disclosure of sensitive information, including AIDS, drug abuse, and mental health records.
Revocation of Authorization Patients may revoke their authorization in writing, but the revocation does not affect prior disclosures.
Expiration of Authorization The authorization remains valid for one year unless revoked earlier.
Fees for Copying St. Luke's Hospital may charge reasonable fees for copying information, as allowed by state and federal laws.
Liability Waiver By signing the form, patients release St. Luke’s Hospital from liability regarding the disclosed information.

Guidelines on Utilizing Sl 0427

Once you have all the necessary information at hand, filling out the SL 0427 form is straightforward. Carefully follow the steps below to complete the authorization process for the release of your protected health information.

  1. Patient Name: Clearly print your full name in the designated space.
  2. Date of Birth: Enter your date of birth in the format requested on the form.
  3. Social Security Number: Provide your Social Security Number, ensuring that all digits are correct.
  4. Date of Service: Indicate the date of the medical service you are authorizing for release.
  5. Purpose of Request: State the reason for requesting your records. This may be anything from legal purposes to personal review.
  6. Name of Person/Organization: Write the name of the individual or organization to whom the records will be released.
  7. Address: Fill in the complete mailing address for the person or organization named above.
  8. Record Selection: Circle one option between "Complete medical record(s)" or specific documents like "Discharge Summary," "Progress Notes," etc.
  9. Special Information: If applicable, indicate if you approve the release of information related to AIDS, drug or alcohol use, or mental health by checking any relevant boxes.
  10. Exclusions: Check any boxes for information you do NOT want to release.
  11. Signature: Sign the form to authorize the release of your information.
  12. Date: Record the date you are signing the form.
  13. Relationship to Patient: If signing on behalf of another person, specify your relationship to the patient.

After completing the form, make sure to review everything for accuracy. Keep a copy of the signed form for your records. Once submitted, St. Luke’s Hospital will process your request in accordance with their policies and relevant laws.

What You Should Know About This Form

What is the purpose of the SL 0427 form?

The SL 0427 form, also known as the Authorization for Use and Disclosure of Protected Health Information (PHI), is used to give permission for St. Luke’s Hospital to release a patient’s medical records. Patients can select specific information to disclose and specify the person or organization receiving the records. This provides a controlled way for patients to manage who accesses their healthcare information.

What types of medical records can be authorized for release?

Patients can choose to authorize the release of their complete medical records or specific documents. Options include discharge summaries, progress notes, lab results, radiology reports, and consultation reports, among others. Additionally, there is a section to include any other specific records that the patient may wish to disclose.

Can patients revoke their consent after signing the form?

Yes, patients may revoke their authorization at any time in writing. It’s important to note that this revocation will not affect any information that has already been used or disclosed prior to the hospital receiving the written notice. The authorization will automatically expire one year from the date it was signed unless a different expiration date is specified.

Is the patient required to sign this authorization to receive treatment?

No, signing the SL 0427 form is not a requirement for receiving treatment at St. Luke’s Hospital. Patients can choose not to sign the authorization without any impact on their ability to access care. This ensures that patients have autonomy over their health information while still receiving necessary medical services.

Are there any fees associated with obtaining copies of medical records?

Yes, St. Luke’s Hospital may charge reasonable fees for copying the requested medical records, whether they are being requested for personal use or for a third party. The fees will conform to applicable state and federal laws regarding the provision of health information.

Common mistakes

When completing the SL 0427 form, individuals often make critical mistakes that can delay processing or lead to the unauthorized release of sensitive information. One common error is leaving out vital personal details. For example, failing to include the patient's date of birth or social security number can result in confusion or misidentification. This information is crucial for the correct handling of medical records, and any omissions might complicate the request.

Another frequent mistake is not specifying the purpose of the request. The form requires clear indication regarding why the health information is being requested. Failure to outline the purpose can lead to questions from the hospital, increasing processing time. It is essential to be explicit, as this helps the employees at St. Luke's Hospital understand the context and urgency of the request.

Additionally, individuals may overlook the options regarding the types of information to be disclosed. Many might check the box for “Complete medical record(s)” without realizing this could include sensitive information they may not want to share, such as mental health records or substance abuse treatment. It is vital to carefully consider and select only the records necessary for the intended purpose.

Finally, neglecting to sign the form or forgetting to include the date can invalidate the entire request. An unsigned form cannot be processed, and the hospital will be unable to release any information until all required signatures and dates are provided. Taking these precautions can help ensure that the SL 0427 form is completed correctly, facilitating a smoother process for obtaining necessary medical records.

Documents used along the form

The SL 0427 form is an essential document for authorizing the release of protected health information (PHI) from St. Luke’s Hospital. Several other forms and documents are commonly used alongside this authorization to ensure a comprehensive approach to patient care and compliance with health information laws. Below are five such documents.

  • SL 0428 - Patient Request for Access to Medical Records: This form enables patients to formally request access to their medical records. It outlines the process for patients who wish to review or obtain copies of their records, ensuring they are informed of their rights under federal and state laws.
  • SL 0429 - Consent for Treatment: This document is required for patients to give their consent for medical treatment. It serves to inform patients about the procedures they will undergo and any associated risks, allowing them to make informed choices about their healthcare.
  • SL 0430 - Patient Notification of Privacy Practices: This form outlines the hospital’s privacy practices regarding the handling of PHI. Patients receive this document to understand how their information is used and safeguarded, ensuring compliance with the Health Insurance Portability and Accountability Act (HIPAA).
  • SL 0431 - Revocation of Authorization: This form allows patients to revoke any previously granted authorizations for the use and disclosure of their PHI. It provides a straightforward process for patients to retract consent, ensuring their preferences are respected regarding personal information.
  • SL 0432 - Release of Information for Billing Purposes: This document facilitates the release of medical information specifically for billing and insurance claims. It ensures that necessary health information is shared with relevant parties for processing payments and claims efficiently.

Understanding these documents in conjunction with the SL 0427 form ensures a clear process for patients regarding their medical records and health information management. Each form plays a crucial role in protecting patients' rights while facilitating effective healthcare delivery.

Similar forms

  • HIPAA Authorization Form - Similar to the SL 0427 form, this document allows individuals to authorize the sharing of their protected health information under the Health Insurance Portability and Accountability Act. It outlines what information can be shared and to whom.
  • Medical Release Form - This document is used by patients to give permission for healthcare providers to share their medical records with third parties, much like the SL 0427 form does.
  • Patient Consent Form - Patients use this form to grant consent for specific medical treatments or procedures. The structure and purpose of this document resonate with the SL 0427 form’s emphasis on informed consent.
  • Information Release Waiver - Similar in intent, this waiver allows patients to authorize the release of their health information for reasons other than treatment, reflecting aspects of the SL 0427 form.
  • Authorization for Release of Educational Records - Like the SL 0427 form, this document permits the sharing of sensitive information but focuses on educational rather than medical records.
  • Release of Information for Insurance Purposes - This form allows health information to be shared with insurance companies for claims processing, mirroring the authorization process found in the SL 0427 form.
  • Release of Medical Information for Legal Purposes - This document shares health information in legal contexts, paralleling the SL 0427 form's theme of controlled information dissemination.
  • Substance Abuse Treatment Records Release - This specialized form addresses the handling of sensitive substance abuse records, resonating with the SL 0427’s emphasis on protecting certain health information.
  • Organ Donation Authorization Form - While geared towards organ donation, this document similarly requires consent and details about what is to be shared or released, akin to the SL 0427 form.

Dos and Don'ts

When filling out the SL 0427 form, here are five important things to do:

  • Provide accurate information for Patient Name, Date of Birth, and Social Security Number.
  • Clearly indicate the Purpose of Request to avoid any confusion.
  • Check the specific records you authorize for disclosure.
  • Review the information carefully before signing to understand your rights.
  • Keep a copy of the completed form for your records.

Conversely, here are five things you should not do:

  • Do not leave any required fields blank.
  • Avoid using unfamiliar terms; use clear and simple language.
  • Do not forget to include the Date of Service.
  • Never check the boxes for information you wish to protect without considering consequences.
  • Do not assume the hospital is responsible for understanding your instructions; be explicit.

Misconceptions

Misconceptions about the SL 0427 form can lead to confusion regarding the authorization for use and disclosure of protected health information (PHI). Here are some common misunderstandings:

  • Only St. Luke’s Hospital can request the form. Many believe that only the hospital can prompt the completion of this form. In reality, patients can initiate the request to release their own medical information.
  • Signing the SL 0427 form is mandatory for treatment. Some individuals think that signing this authorization is a requirement to receive medical care. However, St. Luke’s Hospital does not require the form to provide treatment.
  • The information provided can be shared without restriction. A common misunderstanding is that once the form is signed, the information can be circulated freely. In fact, the recipient is subject to re-disclosure laws, meaning they must adhere to confidentiality when handling the information.
  • The authorization remains valid indefinitely. Many believe that once signed, the authorization lasts forever. In actuality, it expires one year from the signature date unless a different expiration is specified.
  • Patients have no control over what is disclosed. Some think they must release all medical records without exception. However, patients can specify what information to disclose and may check items they wish to exclude.
  • Revocation of the authorization is impossible. A misconception persists that once the form is signed, it cannot be revoked. Yet, patients can revoke their authorization at any time with a written notice.
  • The hospital charges excessive fees for copies of records. Many fear high costs when requesting copies of their medical records. While there can be reasonable fees for copying, these charges must comply with state and federal laws, ensuring they are not excessive.

Understanding these points can help clarify the process and empower patients when dealing with their medical records.

Key takeaways

When dealing with the SL 0427 form, which is the authorization for the use and disclosure of protected health information (PHI), there are several important points to keep in mind:

  • Understand the Purpose: This form allows patients to authorize St. Luke’s Hospital to share their medical records with designated individuals or organizations. It’s crucial to specify who receives your information and for what purpose.
  • Choose Wisely: Patients can choose to disclose their complete medical records or specific documents such as progress notes or laboratory results. Be clear about what information you want to share.
  • Know Your Rights: You have the right to revoke this authorization at any time. However, any actions taken before your revocation remains valid.
  • Beware of Re-disclosure: Once your information is shared, the recipient may re-disclose it, which can lead to unintended sharing of sensitive information.

Filling out the SL 0427 form correctly is essential for ensuring your medical information is handled as you intend.