| Description | Download |
|---|---|
| Authorization for release of medical records and information Signing this form allows Northside to share a patient's protected health information (PHI) with specified individuals or organizations, according to the details stipulated in the form by the patient. | English, Spanish, Korean |
| Request for correction/amendment of protected health information This form allows patients to request a change, edit, or update on their health information record maintained by Northside. | English, Spanish |
| Request for accounting of certain disclosures of protected health information This form allows patients to receive an accounting of disclosure of their health information that was made for purposes other than treatment, payment, or health care operations. | English, Spanish |
| Request for limitations and restrictions of protected health information This form is used to restrict the use and/or disclosure of patient’s health information by Northside. This form is not applicable during emergency treatments. | English |
| HIE Opt-Out This form allows you to decline participation in the Health Information Exchange (HIE), which disables electronic sharing of your health information between your healthcare providers to improve coordination of your care. | English |
| HIE Opt-Out Revocation This form allows you to revoke your previous HIE Opt-out decision. By signing, you choose to opt in and participate in all HIEs selected by Northside. | English |