Authorization for Use or Disclosure of Health Information
7210 Murray Drive, Stockton, CA 95210
Medical Records Phone Number: 209-546-3870
To be completed by the patient or the patient’s authorized representative:
Note: Please Do Not send records via CD, E-Fax is preferred.
A separate authorization is required to authorize the disclosure or use of psychotherapy notes, as defined in the federal regulations implementing the Health Insurance Portability and Accountability Act.
My authorization is given freely with the understanding that:
Please allow a minimum of 15 days for records to be copied and made available.