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.
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
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:________