Records release

Authorization to Release Information

HIPAA authorization for us to discuss your care with family or other providers.

About this form

Many of our patients allow family members — spouses, significant others, caregivers, parents, children — and other healthcare providers to call and request results of tests, procedures, and financial information. HIPAA requires your written consent before disclosing protected health information. You may revoke this authorization at any time by submitting a request in writing.

!This authorization allows the people you list to receive information by phone or in writing.
!You can revoke it at any time by sending us a written request.

Progress

Authorized individuals

List up to four people we may speak with about your care or financial information.

Authorized person 1 — full nameRelationship to patientAuthorized person 2 — full nameRelationship to patientAuthorized person 3 — full nameRelationship to patientAuthorized person 4 — full nameRelationship to patient

Voicemail & messaging preferences

Initial each statement that applies.

Voicemail authorizations

I authorize detailed messages on my home or cell voicemail regarding appointments.I authorize detailed messages on my home or cell voicemail regarding medical treatment, care, test results, or financial information.I authorize the office to leave messages with anyone who answers the phone.Limit messages to specific individuals only (listed above).

Sign & submit

Patient name *Date of birth *Email address *Patient signature (type your full name) *Date *

Acknowledgement. By submitting this form I confirm that I have read and understood the authorizations selected above and that they accurately reflect my preferences.

Submitting transmits this form securely to our office. For urgent medical issues please call our office or 911.

Trouble with the form?

Call our office and we'll either walk you through it or send a paper version.

Call (916) 677-4744 ← All forms