Request/Authorization for Use or Disclosure of Health Information

Request/Authorization for Use or Disclosure of Health Information

Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information requested may invalidate the authorization.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security No.
Representation*

I am the patient named above and I am completing this form myself.I am not the patient named above and I am completing this form as a parent, legal guardian, conservator, executor or next-of-kin.I am an attorney representing the patient named above.I am serving a subpoena for medical records of the patient named above.
Representative Name

First NameLast Name
Relationship to Patient
Law Office or Court of Jurisdiction
Patient

For protection of your privacy, we require a true, correct and legible copy of a valid government-issued photo ID that we may use to verify your identity. If you will be picking up your records in person, you will be asked to provide valid government-issued photo ID at that time, as well.
Patient Representative

For protection of the patient's privacy, we require a true, correct and legible copy of your valid government-issued photo ID that we may use to verify your identity. If you will be picking up records in person, you will be asked to provide valid government-issued photo ID at that time, as well.

In addition to your valid photo ID, please include a copy of the patient's valid government-issued photo ID, if applicable, as well as supporting documentation that gives you authority to request records on behalf of the patient. Acceptable forms of documentation include: death certificate*; executor of the estate (for deceased patients only); power of attorney (must include a provision that allows medical decision-making and/or release of medical records); power of attorney for health care (must include a provision that allows release of medical records); or other form of documentation, subject to review.

*If a death certificate is the only supporting documentation provided, you (the patient's representative) must be listed on the death certificate.
Patient's Attorney

For protection of the patient's privacy, we require a true, correct and legible copy of the patient's valid government-issued photo ID, as well as a complete and legible medical record information release (HIPAA) authorization form signed by the patient.
Court Order or Subpoena

Include a true, correct and legible copy of the court order, or the valid subpoena for medical records and evidence that notification requirements have been met, if applicable.
Patient ID
Upload a true, correct and legible copy of the patient's valid government-issued photo ID.
Patient Representative ID
Upload a true, correct and legible copy of the patient representative's valid government-issued photo ID.
Proof of Representation
Upload a true, correct and legible copy of the death certificate; executor of the estate (for deceased patients only); power of attorney (must include a provision that allows medical decision-making and/or release of medical records); power of attorney for health care (must include a provision that allows release of medical records); or other form of documentation, subject to review. Note that a death certificate, when used as the only form of supporting documentation, must list the name of the patient representative submitting this request.
HIPAA Authorization
Upload a true, correct and legible copy of the medical record information release (HIPAA) authorization form signed by the patient.
Court Order or Subpoena
Upload a true, correct and legible copy of the court order, or subpoena and evidence that notification requirements have been met, if applicable.
I, the undersigned, hereby authorize Medstar Ambulance of Mendocino County Inc., dba Ukiah Ambulance, to release the health information indicated below to:*
Name of facility, physician, person, etc. to whom record(s) may be released
Mailing Address

Address

Address Line 2

CityState / Province

Postal / Zip Code
Phone*

Area CodePhone Number
Fax

Area CodeFax Number
Email*
example@example.com
The following health information may be released:*

Patient Care Report (PCR)Other
Release health information indicated above for the following date(s) of service:*
Purpose*

PersonalInsuranceDisabilityContinuity of careLegalOther
Delivery*

Pick up in-person at our administrative officeMail directly to the address provided aboveFax directly to the fax number provided aboveEmail directly to the email address provided aboveOther
Expiration

MonthDayYear
If left blank, this authorization expires one (1) year from the date signed below.
Signature*

Patient or patient representative as indicated above. Clear
Date & Time of Signature*

MonthDayYear
DateHourMinuteAM/PM Option
Should be Empty: