Medical Records Request

Health Information Management: 209-546-3870

Fax: 209-762-6808

Email: prforms@cmcenters.org

TO BE COMPLETED BY THE PATIENT OR THE PATIENT'S AUTHORIZED REPRESENTATIVE ANY MISSING INFORMATION CAN DELAY PROCESSING

Name*

First NameLast Name

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.

Email Address

example@example.com

I hereby authorize:

Community Medical Centers, Inc., orProvider or Organization Name

Address of the Provider or Organization

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number of the Provider or Organization

Please enter a valid phone number.

Fax Number of the Provider or Organization

Please enter a valid phone number.

Email Address of the Provider or Organization

example@example.com

To release my confidential health information, as described below, to:

SelfCommunity Medical Centers, Inc. PO Box 779 Stockton, CA. 95201 Fax: 209-762-6808 Email: myfaxmedrec@cmcenters.orgAuthorized designeeProvider or Organization

Address

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Email Address

example@example.com

In the following manner:

EmailFaxPick-up Clinic (please specify below)Other

Pick-up Clinic Location (if checked):

Note: please DO NOT send records via CD

For the following purpose(s):

At the request of patientOther

My authorization is for the use and disclosure of the following records:
Progress Notes, from dates: Date to Date
Medication List, from dates: Date to Date
Hospital Admission and/or ER Records, from dates: Date to Date
Radiology Reports, from dates: Date to Date
Laboratory Results, from dates: Date to Date
Billing Statements, from dates: Date to Date
Complete Immunization Record, from dates: Date to Date
Dental Records, from dates: Date to Date
Other records not listed (specify):   Type a label

I specifically authorize release of the following information (check as appropriate):

Mental health treatment informationHIV test results and treatmentsAlcohol/drug treatment information

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): Start Date to End Date

I specifically authorize release of the following information (check as appropriate):
Mental health treatment information Initials*; dates Date    to Date
HIV test results & treatments Initials*; dates Date to Date
Alcohol/drug treatment information Initials*; dates Date   to   Date

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 specific dates are requested above, 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.

This authorization will expire on (if not specified valid for 1 year from date signed below)

Date

Patient's Signature

Date

Name of Parent or Personal Representative

Date

Description of Personal Representatives Legal Authority to Act on Behalf of Patient