The Christ Hospital
Cincinnati OH 45219
Protected Health Information ("PHI") under HIPAA is defined as information that is received from, or created or received on behalf of The Christ Hospital and is information about an individual which relates to past, present or future payment for the provision of health care to an individual; and that identifies the individual, or there is a reasonable basis to believe the information can be used to identify the individual.
PHI includes information of persons living or deceased. The following components of a patient's information are also considered PHI: a) names; b) street address, city, county, precinct, zip code; c) dates directly related to an patient, including birth date, admission date, discharge date, and date of death; d) telephone numbers, fax numbers, and electronic mail addresses; e) Social Security numbers; f) medical record numbers; g) health plan beneficiary numbers; h) account numbers; i) certificates/license numbers; j) vehicle identifiers and serial numbers, including license plate numbers; k) device identifiers and serial numbers; l) Web Universal Resource Locators (URLs); m) biometric identifiers, including finger and voice prints; n) full face photographic images and any comparable images; and o) any other unique identifying number, characteristic, or code.
Date of Birth
Expected Due Date
Information sent from/to OmniSpear
Reasons needed: Platform functionality and customization; user experience I understand that if the person/entity that receives the above protected health information is not a health care provider/health plan covered by federal privacy regulations, the protected health information described above may be re-disclosed by such person/entity and will likely no longer be protected by the federal privacy regulations.
I understand that I/my legal representative may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment or payment or my eligibility for benefits, unless the treatment is for research purposes or unless the provision of treatment is related solely to the disclosure of my PHI to a third party such as when requested by my employer. This authorization will not expire unless otherwise specified.
I hereby authorize the use of disclosure of my protected health information as described above. I authorize the hospital to release the protected health information concerning treatment as diagnosis, or testing of drug or alcohol abuse, drug-related conditions, alcoholism, psychiatric/psychological conditions, Acquired Immune Deficiency Syndrome (AIDS), and/or test for antibodies to the AIDS virus (HIV).