Authorization for Disclosure of Medical Information from Dr. Atiga

Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
PATIENT FULL NAME*
PHONE*
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*
CITY*
STATE*
ZIP*
INFORMATION TO BE USED/DISCLOSED (PLEASE INITIAL) Please write N/A if not applicable and initial the correct box.
ENTIRE RECORD

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SPECIFIC INFORMATION

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Specify date of service, vaccines, sick visits, lab results, x-ray results, etc., describe in detail beneath. Provide Exact description of what records you are requesting and how to send it (mail, email, fax) and provide the appropriate email address or fax #*
I hereby consent to the release of records pertaining to the treatment/diagnosis of the following. Please initial to authorize release
Drug and/or Alcohol Abuse

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Psychiatric/Psychological Treatment

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AIDS/HIV Info.

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THE INFORMATION WILL BE RELEASED FROM JON J. ATIGA M.D., INC.

Jon J. Atiga M.D., Inc. will not be held liable for any misuse or misunderstanding of the information contained herein as a result of this release. I understand that Jon J. Atiga M.D., Inc. reserves the right to deny release of records from other physicians.
PERSONS OR COMPANY INFORMATION MAY BE DISCLOSED/RELEASED TO: (specify name and organization/address/phone number/fax number or email address if applicable. List persons to receive and how to send it to them (mail, fax, email)*
Phone#*
Fax#*
Please enter a valid phone number.
Reason for release*
The authorization is effective through *

MonthDayYear
Date
unless revoked or terminated by the patient/patient's personal representative. You may revoke or terminate this authorization by submitting a written revocation to Jon J. Atiga M.D., Inc. If fail to specify an expiration date this authorization will
SIGNATURE OF PATIENT (legal guardian)*

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Please print your name.
RELATIONSHIP TO PATIENT*
DATE*

MonthDayYear
Date
Upload your Driver's License (Parent / Legal Guardian)*

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25405 Hancock Ave. Ste. 108 Murrieta, Ca 92562

(951) 304-7854 Fax (951) 304-7855
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Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION

INFORMATION TO BE USED/DISCLOSED (PLEASE INITIAL) Please write N/A if not applicable and initial the correct box.