📄 urosurveyauth.ascx
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<%@ Control CodeBehind="UroSurveyAuth.ascx.cs" Language="c#" AutoEventWireup="false" Inherits="Caisis.UI.Modules.All.PaperForms.UroSurveyAuth" %>
<link href="../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<style type="text/css">
<!--
.blackBoldTextLarge {
font-family: Helvetica, Verdana, Arial, sans-serif; font-size: 14px; font-weight: bold;
}
-->
</style>
<div align="center">
<table width="700" border="0" cellpadding="0" cellspacing="0" bgcolor="ffffff">
<tr>
<td align="center"><font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION
- HANDLE ACCORDING TO MSKCC POLICY</font> </td>
</tr>
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="700" cellpadding="1" cellspacing="0">
<tr>
<td width="350" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" alt="" width="80" height="80" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
</span><span class="blackBoldTextLarge"><br>
HIPAA Patient Authorization<br>for Post-Treatment Follow-up</span><br> </td>
<td width="325" align="center" valign="bottom" > <table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
<td align="right">
<% =patientMRNLabel %>
</td>
<td align="left"><strong>
<% =patientMRN %>
</strong>
<% =patientDOB %>
</td>
</tr>
<tr>
<td colspan="1" align="right">
<% =patientNameLabel %>
</td>
<td colspan="1" align="left"><strong>
<% =patientLastName %>
,
<% =patientFirstName %>
<% =patientMiddleName %>
</strong></td>
</tr>
<tr>
<td align="right" valign="top">
<% =patientAddressLabel %>
</td>
<td align="left" valign="top">
<% =patientAddress1 %>
<% =patientAddress2 %>
<% =patientCity %>
<% =patientState %>
<% =patientPostalCode %>
</td>
</tr>
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
</tr>
<tr>
<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient
Identification</td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="100%" border="0" cellspacing="0" cellpadding="14">
<tr>
<td>We understand that information about you and your health is personal,
and we are committed to protecting the privacy of that information.
Because of this committment, we must obtain your written authorization
before we may use or disclose your protected health information
for the purposes described below. This form provides that authorization
and helps us make sure that you are properly informed of how this
informed of how this information will be used or disclosed. Please
read the information below carefully before signing the form.<br>
<br>
<table width="670" border="0" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr >
<td height="30" colspan="5" align="center" class="blackBoldTextLarge">USE
AND DISCLOSURE COVERED BY THIS AUTHORIZATION</td>
</tr>
<tr >
<td> </td>
<td colspan="4" class="blackBoldText">May we contact, or continue
to contact, your physician(s) to obtain copies of your medical
records to update our files?</td>
</tr>
<tr >
<td> </td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
No </td>
<td colspan="3"><em>If Yes, please provide all of the requested
information below.<br>
If No, you may skip to Page 2 of this form.</em></td>
</tr>
<tr >
<td height="40"> </td>
<td height="40" class="blackBoldText">Who will disclose this
information?</td>
<td height="40"> </td>
<td height="40"> </td>
<td> </td>
</tr>
<tr >
<td> </td>
<td colspan="4"><table width="550" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="blackBoldText"><img src="../../Images/shim.gif" width="10" height="8"></td>
<td height="23" class="blackBoldText">Physician Role</td>
<td>Following / Treating (Circle
One) </td>
</tr>
<tr>
<td class="blackBoldText"> </td>
<td height="26" class="blackBoldText">Physician Name (Last,
First)</td>
<td>______________________________________________</td>
</tr>
<tr>
<td class="blackBoldText"> </td>
<td height="26" class="blackBoldText">Address</td>
<td>______________________________________________</td>
</tr>
<tr>
<td class="blackBoldText"> </td>
<td height="26" class="blackBoldText">City / State / Zip</td>
<td>______________________________________________</td>
</tr>
<tr>
<td class="blackBoldText"> </td>
<td height="26" class="blackBoldText">Office Phone</td>
<td>______________________________________________</td>
</tr>
</table></td>
</tr>
<tr >
<td colspan="5" valign="top"> </td>
</tr>
<tr >
<td valign="top"><img src="../../Images/shim.gif" width="10" height="8"></td>
<td height="23" valign="top" class="blackBoldText">Who will
use and/or disclose this information? </td>
<td><img src="../../Images/shim.gif" width="10" height="8"></td>
<td colspan="2" valign="top">Memorial Sloan-Kettering Cancer
Center Department of Urology</td>
</tr>
<tr >
<td valign="top"> </td>
<td height="23" valign="top" class="blackBoldText">What information
will be used and disclosed?</td>
<td> </td>
<td colspan="2" valign="top">Consults, progress notes, lab and
pathology reports, treatment records.</td>
</tr>
<tr >
<td valign="top"> </td>
<td height="23" valign="top" class="blackBoldText">What is the
purpose of the use or disclosure?</td>
<td> </td>
<td colspan="2" valign="top">To update Department of Urology
patient records.</td>
</tr>
<tr >
<td width="10" valign="top"> </td>
<td width="270" height="23" valign="top" class="blackBoldText">When
will this authorization expire?</td>
<td width="10"> </td>
<td width="80" valign="top">Choose Either:</td>
<td width="300" valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Expires on ______ / ______ / _________ (date)</td>
</tr>
<tr >
<td> </td>
<td> </td>
<td> </td>
<td> OR:</td>
<td> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
No expiration date</td>
</tr>
</table>
<br> <table width="670" border="0" cellspacing="0" cellpadding="4">
<tr>
<td height="30" align="center" class="blackBoldTextLarge">SPECIFIC
UNDERSTANDINGS</td>
</tr>
<tr>
<td>By signing this authorization form, you authorize the use
or disclosure of your protected health information as described
above. This information may be redisclosed if the recipient(s)
described on this form is not required by law to protect the
privacy of the information, and such information is no longer
protected by federal health information privacy regulations.<br>
<br>
You have the right to refuse to sign this authorization. Your
health care, the payment for your health care, and your health
care benefits will not be affected if you do not sign this
form.<br> <br>
You have a right to see and copy the information described
on this authorization form in accordance with hospital policies.
You also have a right to receive a copy of this form once
you have signed it.<br> <br>
If you sign this authorization, you will have the right to
revoke it at any time, except to the extent that the hospital
has already taken action based upon this authorization. To
revoke this authorization, please write to Urology Post Treatment
Survey or the Privacy Office at the hospital.</td>
</tr>
</table>
<br> <table width="670" border="0" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr >
<td height="30" colspan="5" align="center" class="blackBoldTextLarge">SIGNATURE</td>
</tr>
<tr >
<td width="10" height="40"> </td>
<td width="660" height="40" colspan="4"><em>I have read this
form and all my questions about this form have been answered.
By signing below, I acknowledge that I have read and accept
all of the above.</em></td>
</tr>
<tr >
<td> </td>
<td colspan="4"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="300" height="24" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="300" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td>Signature of Patient or Personal Representative</td>
<td> </td>
<td>Date</td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
</tr>
<tr>
<td colspan="3" class="blackBoldTextSmall"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="300" height="24" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="83" class="FormInnerRowBottomBorder"> </td>
<td width="50"> </td>
<td width="167" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td valign="top">Print Name of Patient or Personal
Representative</td>
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