These forms can be found via the "Forms" link on the Intranet home page. Click here for the English release form. Click here for the Spanish version. These forms should be used in order to document a patient's consent for photography/videography or information release in any public relations or medical education situations.
After the form is signed, please photocopy it and provide one copy to the patient, one copy to the News Office (firstname.lastname@example.org or in person at 20610 Neurosciences Hospital), and one copy to Medical Information Management (by fax at 919-966-0839, at email@example.com, or in person).
Please follow these procedures when emailing the complete form to Medical Information Management:
- All files must be sent the inbox named “MIM Department” in Adobe .pdf format
- All file names must conform to the following naming convention: First 7 digits of the patients MR#, followed by an underscore, followed by the date sent or date created. Include all leading zeroes, but do not include the check digit. E.g. 0034567_MMDDYYYY.
- Each .pdf file sent can only contain one document, although a single email may have several attached files. When External Records are sent from an outside facility, all records together are considered a single document.
- All files must have the Patients name and MR# on each page.
- A contact person who is able to troubleshoot problems must be included with each email.
- When you have confirmed that your documents are visible in WebCIS, delete or shred the original. Do not send duplicate copies of emailed documents.
If you have questions about these procedures, please call Medical Information Management at 966-2312. If you have questions about the Patient Information Release forms, please call the News Office at 966-3367.