Records release

Patient Authorization Form — 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 such as their spouse, significant other, caregiver, parents, or children to call and request the result of tests, procedures, and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

Progress

Patient information

Patient name *Date of birth *

I authorize Sierra Rheumatology to release my records and any information requested to the following individuals.

1. Full name1. Relation to patient2. Full name2. Relation to patient3. Full name3. Relation to patient4. Full name4. Relation to patient

Authorization Regarding Messages

Please check all that apply.

I authorize you to leave a detailed message on my home or cell number regarding appointments.

Yes, I authorize this

I authorize you to leave a detailed message on my home or cell number regarding medical treatment, care, test results or financial information.

Yes, I authorize this

I authorize you to leave a message with anyone who answers the phone.

Yes, I authorize this

Messages may only be left with (specify name(s)):

Sign & submit

Patient signature *Sign with your finger, mouse or trackpad in the box below.

Sign here with your finger, mouse or trackpad

Your signature will appear on the exported PDF.

Date signed *Email address (so we can confirm receipt) *

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. Export to PDF works even with partial answers — useful if you want a printed copy to bring in. 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