![]() Access to your information requires entry of a personalized username and password by CC HIMD staff. The system uses appropriate administrative, technical and physical controls for protection of information contained therein and is protected by multiple firewalls, vulnerability scanning, and advanced encryption technology. BOX maintains approved physical, electronic and procedural safeguards to comply with federally approved standards to guard your nonpublic personal information. If you do not wish to use this service, but still wish to send the signed document, you may mail the document to CC Health Information Management Department, 10 Center Drive, Room B1L400, MSC 1192 Bethesda, MD 20892 or fax to 30.Īt all times, security maintenance and administration is an important part of website operations and maintenance. Please note that by voluntarily providing your information and uploading documents into this site, you are accepting the practices described in this Privacy Notice and consent to the collection, storage, and use of personal information about you as described in this Notice. The information collected reflects the minimum necessary to accomplish the purpose of uploading the signed Authorization for the Release of Medical Information form, and other patient completed authorization forms (patient portal consents, etc.) to the CC Health Information Management Department.īy using the third-party BOX Website to send signed document(s) to the NIH CC Health Information Management Department, you may be providing nongovernmental third-parties with access to PII and/or sensitive information. The BOX application presents a form and asks for your name, your e-mail and an open text message. This Privacy Notice explains the collection and use of Personally Identifiable Information (PII) about you through the CC HIMD Website. Purposes and Use of Information We Collect from You In this instance, the BOX Privacy Policy applies and is located at. ![]() The NIH agency's Privacy Policy located at, but does not apply. The CC Health Information Management Department (HIMD) uses BOX, an NIH approved third party secure file sharing service, to send/ receive forms to registered CC patients. The NIH Clinical Center (CC) is committed to protecting the privacy of CC patient information contained in NIH information systems. For additional details, please contact the Health Information Management Division at 1-88 or review the BOX website. Your file has been uploaded, and the owner has been notified.īOX is a secure commercial site approved by NIH which provides an easy and fast method for sending and receiving large files. You will receive the following message on-screen after the upload has been successful: In the File Description text box, type in your full legal name, date of birth, and any other information you would like to convey with the form (Optional). For consultation regarding who is authorized to sign this form, contact the Health Information Management Division at 1-88.ĭrag and drop your file into the box above or select browse your device to choose your file. There are situations in which this general rule does not apply. If the patient is under the age of 18, the parent or guardian must sign this form. If the patient is 18 years of age or older, the patient is the only person who is permitted to sign this form. ![]() Written Directions for How to Electronically Sign and Submit this form. Written Directions for How to Complete this form. Typed signatures or digital signatures enabled by certificates will not be accepted. NOTE: Authorization forms must include a manual/handwritten signature using paper and pen or a manual/handwritten signature on an electronic device using a mouse, stylus, finger, etc. The Health Information Management Division (HIMD) uses an NIH approved secure file sharing service, BOX, to allow for electronic submission of completed Authorization for Release of Information Forms. This form can be mailed, faxed, or submitted electronically using the below instructions: If you have any questions about how to complete the form or any questions about the release process, please call us at 88. To request a copy of your NIH Clinical Center records, you will need to complete our Authorization for Release of Information form (Para Español Autorización para la Divulgación de Información Médica). How to Request a Copy of Your Medical Records
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