Upham’s Corner Health Committee, Inc.
Upham’s Corner Health Center ~ Upham’s Corner H.C. Pharmacy ~ Upham’s Elder Service Plan ~ Upham’s Home Health
e415 Columbia Road
Dorchester, MA 02125(617) 287 - 8000

AUTHORIZATION FOR RELEASE OF PROTECTED OR PRIVILEGED HEALTH INFORMATION

I, or the parent/guardian of the patient named below, understand that I have the right to inspect my protectedhealth information at UCHC, to receive a copy of my protected health information (or designate and authorizesomeone else to receive a copy of it), or any combination of such. I understand that my request to access myrecords may be subject to some legal limitations and/or limitations established by the federal government and enforced by a licensed healthcare professional to assure my health and safety and the safety of others

PATIENT INFORMATION

  • Upham’s Corner Health Committee, Inc. (UCHC) cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at UCHC may or may not protect this information once it has been released to the recipient.
  • This authorization is voluntary.
  • My treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form.
  • I may revoke this authorization at any time by submitting a written request to the Medical Records Supervisor at UCHC, except: -if action has already been taken in reliance on this authorization. -if the authorization is obtained as a condition of obtaining insurance coverage, other laws provide the insurer with the right to contest a claim under the policy
  • This authorization will automatically expire in 90 days or otherwise as indicated:

I have carefully read and understand the above, have had any questions explained to my satisfaction, and voluntarily authorize disclosure of the above information about, or medical records of, my condition to those persons or agencies listed.

When patient is a minor, or is not competent to give consent, the signature of a parent, guardian, or other legal representative is required.