I understand that I may be charged for my records. I also understand that I can contact Professional Medical Copy at (530) 241-2971 for any questions regarding the associated fees for copying my records
Permissions for further use or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law. A photocopy or facsimile of this authorization shall be considered as effective and valid as the original.
I have been advised of my right to receive a copy of this authorization: