Please use the following forms when you want to give us specific instructions regarding how your personal information is used
or shared with others.
Forms for Belmont Patients:
-
Do Not Contact Form: Use this form if you wish to stop receiving fundraising or marketing information.
- Patient Authorization Forms
-
For Releasing Documents: Use this form when you would like Belmont to release your information to outside parties.
- For Obtaining Documents: Use this form when Belmont needs to obtain your records from another hospital, other doctors or other
healthcare professionals.
-
Patient Revocation of Authorization to Disclose and Use PHI Form: Use this form if you want to revoke (take back) your authorization.
-
Patient Request for Accounting Form:
Use this form to receive an accounting of certain releases of your personal health information. This accounting will not
include information released or used for treatment, payment or operations and it will not include any information we released
with your authorization.
-
Patient Request for Amendment Form: Use this form to request corrections to your medical record.
-
Patient Request for Restrictions Form:
Use this form when requesting that Belmont restrict normal uses of your health information.
Forms for Einstein Patients:
-
Do Not Contact Form: Use this form if you wish to stop receiving fundraising or marketing information.
- Patient Authorization Forms
-
Patient Request for Accounting Form:
Use this form to receive an accounting of certain releases of your personal health information. This accounting will not
include information released or used for treatment, payment or operations and it will not include any information we released
with your authorization.
-
Patient Request for Amendment Form: Use this form to request corrections to your medical record.
-
Patient Request for Restrictions Form: Use this form for requesting that Einstein restrict normal uses of your health information.
