Authorization to Release Medical Information

Authorization to Release Medical Information

Individual
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Patient*
Please enter a valid phone number.
Name of the individual authorized to speak about the above patient*

First NameLast Name
Relationship to Patient:Relationship*
Phone Number for Authorized Individual*
Please enter a valid phone number.
Expiration Date for Authorization*

MonthDayYear
Date
The following information is authorized for release to the individual named above*

Appointments/SchedulingBilling/PaymentsMedication RefillsTest ResultsVisit NotesAll Information
Restriction: I understand that the information release may be subject to re-disclosure by the receipient and may no longer be protected (Under California law, however, a recipient of medical information, whether disclosed pursuant to an authorization or to the discretionary provisions of California Civil Code #56.10(x), may not further disclose that medical information except in accordance with a new authorization or as specifically required or permitted by law.)

Rights: I understand that I may refuse to sign this authorization and that my refusal to sign may not affect my ability to obtain treatment. I may inspect or obtain a copy of any information to be used and/or disclosed under this authorization in accordance with organizational policy. I understand that I have the right to revoke this authorization in writing. My revocation will be effective upon receipt, but will not be effective to the extent that this organization has taken action in reliance upon this authorization.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: