CSCM - Authorization for Release of Records

Authorization for the Release of Medical Records

This authorization must be completed, dated and signed by the patient or by a person authorized by law to give authorization. It is valid until revoked in writing. Records are requested for continuity of care. This clinic does not offer reimbursement for records received.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
I for request CSCM to please obtain information from the following provider:
Phone Number of Physician/Practitioner

Area CodePhone Number
Address of Physician/Practitioner

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number for Physician/Practitioner

Area CodePhone Number
Email Address for Physician/Practitioner
example@example.com
Medical information may be sent to:

Chicken Soup Chinese Medicine

2300 Sutter Street, Suite 203

San Francisco, CA 94115

FAX: 415-644-0614 (HIPAA secure fax)
By checking the spaces below, I authorize the above physician/clinic/hospital to release written records pertaining to the following information going back one year. I also authorize the above physician/clinic/hospital to provide the following information via telephone consultation:

Medical records for continuity of careDiagnostic imaging reportsPathology reportsLaboratory reportsOther
I understand that certain information in these records cannot be released without specific authorization because of federal or state laws. By signing the spaces below, I specifically authorize the release of the follwoing confidential information to Chicken Soup Chinese Medicine. I also authorize the above physician/clinic/hospital to provide the following information via telephone consultation:

HIV/AIDS test results and related information, including high risk behavior documentation. This information may not be further disclosed without the specific written authorization of the tested individual.

Drug/Alcohol diagnosis, treatment or referral information. Federal Regulation, 42 CFR Part 2, requires a description of how much and what kind of information is to be Disclosed. Please provide a description of this information.

Mental health treatment information
Patient Signature (or Parent/Guardian if applicable) *

Clear
Please use your finger or mouse to create your e-signature.
Today's Date*

MonthDayYear
Date
---------------------- for office use only ----------------------

Date sent: ______________________________________

Initials: _____________
Should be Empty:

Authorization for the Release of Medical Records