Medical Records Release/Request Form

I hereby authorize,

to release health information on the patient named below:

Patient Name (Print)

Date of Birth

Other Name (i.e. Maiden)

Telephone

Address

City/State

ZIP

I Authorize the Release Of:

ALL my health information maintained Include Previous Provider Records My health information relating to the following treatment or condition (Please fill in the box below) My health information for the date(s) (Please fill in the box below) Other (Please fill in the box below)

Reason For Release (Must be noted)

Send/Release Medical Records To

Address

City

State

Zip

Phone

Fax

RESTRICTIONS: I understand that the recipient of this information may not use or disclose this information except for the expressed purposes identified above, unless another authorization is obtained from me, or such use or disclosure is specifically required or permitted by law. I understand that my medical record may include information relating to sexually transmitted disease; acquired immunodeficiency syndrome (AIDS); human immunodeficiency virus (HIV); behavioral/mental health services; and/or treatment for alcohol and/or drug abuse.

PLEASE Check ALL Requested Exclusions:

I understand that I have the right to request that a service for which I have paid out-‐of-‐pocket, not be disclosed to my health plan.

This Authorization is Effective:

Date

Through (Dates must be specifed)

Signature

PRINT NAME

DATE

REFUSAL TO SIGN AUTHORIZATION: I understand that by declining to sign this form, my medical (healthcare) treatment and insurance benefits will not be affected, however, my medical records CANNOT be released. I understand that I may revoke this authorization at any time by notifying the organization in writing as described in the Notice of Privacy Practices. My revocation will not affect actions taken prior to its receipt. I understand that, if the recipient of the information is not a health care provider or health plan covered by HIPAA, the information used or disclosed as described above may be re-disclosed by the recipient and no longer protected by HIPAA. However, other state or Federal laws may prohibit the recipient from disclosing specially protected information, such as abuse treatment information, HIV/AIDS-related information, and psychiatric/mental health information.

2001 O Street Bakersfield, California

(661) 322-8741

Patient Authorization for Use or Disclosure of Protected Health Information

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