Forms

• Authorization of Release of PHI

Use this form to request a copy of your medical record to be released to the patient or to another person/agency/organization.

• Authorization to Obtain PHI

Use this form to authorize Urology Center of Columbus to obtain a copy of patient’s health information from another provider/agency/organization.

• Request for Accounting Disclosure of PHI

Use this form to request a report that lists when Urology Center of Columbus disclosed a patient’s PHI for purposes other than treatment, payment, or health care operations and without patient authorization to an outside person or entity during a specified time frame.

• Request for Confidential Communication for PHI

Use this form to request confidential communication of their PHI by alternative means.

• Request to Amend Patient Records

Use this form to request that medical record information be amended.

• Request to Inspect or Copy PHI of Deceased

This form is to be used by the legally authorized representative of the deceased patient to request an opportunity to inspect or copy protected health information in the possession of Urology Center of Columbus.

• Restriction of Use and Disclosure of PHI

Use this form when you want to manage who can and can’t see your protected health information.

• Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information.

• Email Consent Form

Use this form to review our email consent policy.