I authorize the release of my health information FROM (organization that will RELEASE your information):Edinger Medical Group9900 Talbert Avenue, Suites 301-302Fountain Valley, CA 92708
To be released TO the following recipient (organization that will RECEIVE your information):Edinger Medical Group9900 Talbert Avenue, Suites 301-302Fountain Valley, CA 92708
If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be disclosed and may no longer be protected. California law prohibits recipients of your health information from redisclosing such information except with your written authorization or as specifically required or permitted by law.
Edinger Medical Group recognizes the patient's right of confidentiality of their health information under federal privacy regulations and California law. The patient should be aware of the following information when requesting or releasing health information.
Right to Refuse to Sign this Authorization: This authorization is voluntary. Refusal to sign will not affect the patient's ability to receive treatment or payment of claims.
Right to Inspect or Receive a Copy of Health Information to be Used or Disclosed: A patient has the right to inspect or obtain a copy of the health information they have authorized to be used or disclosed by signing this Authorization form.
Right to Receive a Copy of this Authorization: A patient has the right to revoke his authorization at any time by giving written notice of revocation to the Privacy Officer. Revocation of this authorization WILL NOT affect any action taken in reliance of this authorization before receipt of the written notice of revocation.
Multiple Releases of Information: A patient may request multiple releases of the information stated on the Authorization form. However, all releases based on this form are limited to records dated up to and including the date of the patient's signature. A new authorization is necessary for release of information for care provided after the date of the patient's signature, UNLESS the authorization specifically states that SPECIFIC RECORDS that will be generated in the future may be released, for example, "future records of a specific test" or "future records of specific clinic appointment."
Who May Sign this Authorization
Fees for Records: Copies of a patient's medical record sent directly to another physician or medical facility will be made generally at no charge; however, if many requests are made, a copying fee may be applied as allowed by California law.
Edinger Medical Group Medical RecordsEmail: medicalrecords@edingermedicalgroup.comFax: 714-965-2595
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