The Provider Request Form must be on the requesting provider's letterhead.  To download, click on the Provider Request Form below to open it and then save the document to your computer.  Print the form on your office letterhead prior to completion and submission for records. If you would like to read a memo of explanation, click here.

Click on link below:

• PHI Request Form  (word document, 25k)
• Memo of Explanation

Memo of explanation

TO: Knoxville Area Clinical Providers  
FROM:  Knoxville Area Hospital HIPAA Officials  

• Baptist Hospital of East Tennessee
• Fort Sanders Parkwest
• St Mary's Medical Center  
• Baptist Hospital of Cocke County
• Fort Sanders Regional
• Jefferson Memorial Hospital  
• Baptist Hospital West
• Fort Sanders Loudon
• St Mary's Campbell County  
• Baptist Hospital for Women
• Fort Sanders Sevier
• St Mary’s Amb. Surgery Center  
• Blount Memorial Hospital
• Methodist Medical Center
• UT Medical Center  
   

DATE:  01-15-04  
RE:  Provider Request Form  

Since the implementation of HIPAA, local area Privacy Officers have worked in collaboration regarding the release of information between providers and what is required to release/share patient information.  Section 164.506 (c) Implementation specifications: Treatment, payment, or health care operations of the HIPAA rules states:  

(2) A covered entity may disclose protected health information for treatment activities of a health care provider.

(3) A covered entity may disclose protected health information to another covered entity or a health care provider for the payment activities of the entity that receives the information.

(4) A covered entity may disclose protected health information to another covered entity for health care operations activities of the entity that receives the information, if each entity either has or had a relationship with the individual who is the subject of the protected health information being requested…  

In an effort to accommodate patient care and provider services while maintaining the integrity of patient confidentiality the attached form may be used to request patient information.  The form provides documentation of patient/provider relationship that many providers feel must be present prior to disclosure of patient information without an authorization.  IF A HOSPITAL’S RECORD DOCUMENTS THE EXISTING RELATIONSHIP, NO ADDITIONAL DOCUMENTATION IS NECESSARY.  
 
 
 
The form should be copied to your office letterhead and used when information is being requested from the Knoxville area hospitals and any other provider who deems it acceptable.  The Knoxville area hospitals listed above agree to accept this form as documentation to satisfy the relationship between the patient and provider.  Please note that some information that is considered sensitive might require an authorization from the patient prior to disclosure.  

Please contact the Privacy Official listed below if you have any questions.  
Baptist Health System-----Brenda Ellis ( 549-2121 )    www.baptistoneword.org