Authorization for Use or Disclosure of Health Information

Authorization for Use or Disclosure of Health Information
7210 Murray Drive, Stockton, CA 95210

Medical Records Phone Number: 209-546-3870

FAX: 209-762-6808

Email: myfaxmedrec@cmcenters.org

To be completed by the patient or the patient’s authorized representative:
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
I hereby authorize:*

Community Medical Centers, Inc., orOther
Other Provider or Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone

Area CodePhone Number
Fax

Area CodePhone Number
To release my confidential health information, as described below, to:*

SelfCommunity Medical Centers, Inc. 7210 Murray Dr. Stockton, CA 95210Authorized designeeOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Email
example@example.com
In the following manner:*

Copies by emailCopies by faxCopies to be picked-up (specify below)Other
Pick-Up Location (if applicable):
Note: Please Do Not send records via CD, E-Fax is preferred.
For the following purpose(s):

At the request of patientOther
My authorization is for the use and disclosure of the following records:*

Provider Progress Notes, Labs, Medication listHospital Admission and/or ER recordsRadiology ReportsLaboratory ResultsBilling StatementsComplete Immunization RecordOther
Date Range (if applicable)

MonthDayYear
Start Date
to
MonthDayYear
End Date
Use this space to provide further date range specifics (if applicable)
I specifically authorize release of the following information (check as appropriate):

Mental health treatment informationHIV test results & treatmentsAlcohol/drug treatment
Initial for mental health treatment information release consent*
Initial for HIV test results and treatments release consent*
Initial for alcohol/drug treatment release consent*
Date Range (if applicable)

MonthDayYear
Start Date
to
MonthDayYear
End Date
Use this space to provide further date range specifics (if applicable)
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:
- I may revoke this authorization in writing at any time, except where information has already been released in reliance on my authorization.
- Unless implied no more than 2 years of records will be sent when requesting “any or all” records.
- CMC may not condition my treatment on the provision of this authorization.
- Information disclosed under this authorization may be subject to re-disclosure by the recipient without further protection of confidentiality.
- A photocopy or fax of this authorization is as valid as the original.
Please allow a minimum of 15 days for records to be copied and made available.
The authorization will expire on:*

MonthDayYear
(if not specified, enter the date 1 year from today)
Signature*

Clear
Date*

MonthDayYear
Date
Name of Parent or Personal Representative (if applicable)

First NameLast Name
Date

MonthDayYear
Date
Description of Personal representative's Legal Authority to Act on Behalf of Patient
Should be Empty: