Authorization for Disclosure of Medical Information from another Doctor

Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
PATIENT FULL NAME
PHONE
Format: (000) 000-0000.
DATE OF BIRTH

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ADDRESS
CITY
STATE
ZIP
I AM REQUESTING MEDICAL RECORDS TO BE RELEASED FROM: (MEDICAL ORG/PHYSICIAN NAME)
NAME
Address

Street Address

Street Address Line 2

CityState

Zip Code
PHONE
Format: (000) 000-0000.
FAX#
Please enter a valid phone number.Format: (000) 000-0000.
I authorize this information to be released to JON J. ATIGA M.D., INC at 25405 HANCOCK AVE. Ste. 108 Murrieta, Ca 92562.

Information to be disclosed/released includes (Please initial)
ENTIRE RECORD
SUBSTANCE ABUSE
PSYCHIATRIC/MENTAL HEALTH INFO.
AIDS/HIV INFO.
SPECIFIC INFORMATION (Specify date of service, vaccines, lab results, x ray results, etc.)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
TERMINATE THIS AUTHORIZATION BY SUBMITTING A WRITTEN REVOCATION TO JON J. ATIGA M.D., INC.
SIGNATURE OF PATIENT (legal guardian)
Please print your name.
RELATIONSHIP TO PATIENT
DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
25405 Hancock Ave. Ste. 108 Murrieta, Ca 92562

(951) 304-7854 Fax (951) 304-7855
Should be Empty:

Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine