PositivePeers-Development

App Registration


Eligibility

Name:
Age:
Date of Birth: //
Year of HIV Diagnosis:
Address:
City:
State:
Zipcode:
Email:
Phone:

App Username:

Consent

 

(0 = no, 1 = yes)

Release of Information

Healthcare Provider:
Patient of Partner Organization:
Doctor's Name:  

If not a MetroHealth or Partner Organization patient:
Hospital/Clinic:
Facility City:
Facility State:
Phone:
Fax:

Authorization to Obtain Medical Records from Another Facility

I hereby grant permission to:
NAME OF PROVIDER:
CITY/STATE: ,
FAX:

TO release a copy of my medical records. I understand that the information released upon authority of this authorization may contain information concerning treatment for a sexually transmitted disease, alcohol, drug abuse, a psychiatric condition, or HIV test results, an AIDS diagnosis, or AIDS-Related condition. I further understand this authorization does not include permission to release outpatient Psychotherapy notes. The release of Psychotherapy notes requires a separate authorization (Psychotherapy notes are separated from the rest of a patient's medical record).

This authorization is valid for a period of 1 year from the date of completion of this authorization, and may be revoked by me in writing at any time, except to the extent that action has been taken in reliance. The revocation must be provided to the MetroHealth Medical Record Department.

SPECIFIC INFORMATION TO BE RELEASED: HIV status, attendance at HIV-related medical visits, CD4 counts and viral loads.

For the following time period: One year prior to today through one year after today.

FOR THE PURPOSE OF: Patient Care

The copy of the medical records is to be released to:
MetroHealth Medical Center
ATTN: Jen McMillen Smith, LISW
Department: Medicine/Infectious Diseases
2500 MetroHealth Drive
Cleveland, OH  44109-4662
Phone: 216-778-4051
Fax: 216-778-4695

PATIENT NAME:
DATE OF BIRTH: //
PATIENT ADDRESS: , ,
TELEPHONE NUMBER:

(0 = no, 1 = yes)

Leave this empty:

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Signature Certificate
Document name: App Registration
lock iconUnique Document ID: d84895a510d9c04ccbe45ab60e41aee5de535032
Timestamp Audit
November 18, 2019 7:19 pm EDTApp Registration Uploaded by Positive Peers - wp@dev.appmaisters.com IP 108.181.157.68
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This audit trail report provides a detailed record of the online activity and events recorded for this document.
https://positivepeers-dev2.appmaister.com/
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