Authorization to Release/Disclose Protected Health Information

Dr. Jones Hormozi, DPM

18840 Ventura Blvd. Suite #211 Tarzana, CA 91356

867 W Lancaster Blvd. Lancaster, CA 93534

PH: 818-981-1900 | FAX: 866-254-5997
Authorization to Release/Disclose Protected Health Information
Patient Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Apt, Suite, etc.

CityState / Province

Postal / Zip Code
PhysicianOther
Name of person or entity to receive information*

First NameLast Name
Address (whom is receiving information)*

Street Address

Apt, Suite, etc.

CityState / Province

Postal / Zip Code
Office Phone Number (required if faxing)*
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number (25 pages or less)*
Please enter a valid phone number.Format: (000) 000-0000.
Complete Medical RecordSpecific Date(s) of Service: (request dates in "other" option)Billing InformationOther
Medical Follow-UpAttorneyPersonal UseInsuranceOther
Please mail the recordsFax to number aboveI will pick up the recordsOther
**Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.**
This authorization will expire on the following date, event, or condition: Fill in the blank* . If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from date signed.

I understand if the person or agency that receives my information is not a health care provider or health plan covered by the HIPAA privacy regulations, the information described above may be re-disclosed and is no longer protected by these regulations.
Print Name of Patient or Authorized Representative*

First NameLast Name
Relationship to Patient*
Signature of Patient or Authorized Representative*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: