PRC Authorization for the Use and Disclosure of Medical Information

Authorization for the Use and Disclosure of Medical Information
This authortization allows the healthcare provider(s) named below to release confidential medical information and records. Note: Information and records regarding treatment of minors, HIV, psychiatric/ mental health conditions, or alcohol/substance abuse have special rules that require specific authorization.

AUTHORIZATION:

I hereby authorize the receipt of this request to release information regarding my medical history, illness, or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records by mean of mail, fax or other electronic methods.

TO: PACIFIC REPRODUCTIVE CENTER

3720 Lomita Blvd, Suite 200
Torrance, CA 90505

Email: info@pacificreproductivecenter.com
Phone # 866-423-2645 Fax # 951-371-9400

The Medical records will be used for the following purposes:

_____________________________________________________

Authorization is effective immediately and remains effective until:________
This Authorization is for*

Unlimited (All records, excluding HIV diagnosis/treatment, substance abuse and Mental Health)Limited to the medical information pertaining to:
I also consent to the release of the following records: (please select each below and initial below)*

Drug/AlcoholTests for antibodies to HIVPsychiatric Mental/HealthHIV diagnosis/treatmentGenetic Testing (which is recommended for the treatment of fertility
Initials for the authorization of the above checked items to be included in release of records.*
Restrictions

Permissions for further use or disclosure of this medical information is not granted unless another authorization is obtained from or unless such disclosure is specifically required or permitted by law. A photocopy or facsimile of this authorization shall be considered as effective and valid as the original.

I have been advised of my right to receive a copy of the Authorization.
Patient Name*

First NameLast Name
Date*

MonthDayYear
Patient's Last 4 of SS #*
Signature of Patient (or Legal Representative)*

Clear
Relationship to Patient*
(ex. Self/Spouse/Guardian)
Date*

MonthDayYear
Date
Should be Empty: