Medical Records Form

Home  

 
 

AUTHORIZATION FOR USE OR DISCLOSURE
OF
HEALTH INFORMATION

 

Patient: ___________________________________________________________

Date of Birth: __________________ Medical Record Number: _______________

 

I hereby authorize:

to Release Information to:

Colusa Regional Medical Center

________________________________

199 E Webster Street

Name of Recipient

Colusa, CA  95932

________________________________

Phone: (530) 458-1924

Address

Fax: (530) 619-0298

_________________________

 

City / State / Zip

______________________________

________________________________

Phone / FAX

The following information:

Most Recent         Discharge Summary     History and Physical    Laboratory results Emergency Room Visits    Operative / Procedure Reports

X-ray / Imaging Reports X-ray Film of ___________________________________(dates) 

Summary of Care Records from Clinic __________________________________________                 

Other _____________________________________________________________________

  All health information pertaining to my medical history, mental or physical condition and treatment received.  I understand that copy fees may apply.

 

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

Mental health information   HIV test results    Alcohol/drug information

 

PURPOSE Patient request; - OR-           Other need:____________________________

EXPIRATION:   This authorization expires on __________________________(date).

If I fail to specify an expiration date, this authorization will expire in six months.

 

RIGHTS:  I may refuse to sign this Authorization.  My refusal will not affect my ability to obtain treatment.  I have a right to receive a copy of this authorization.  I may revoke this authorization at any time, but I must do so in writing and submit it to CRMC 199 E. Webster Street, Colusa, CA 95932.  My revocation will take effect upon receipt, except to the extent others have acted in reliance upon this Authorization.  I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. 

 

SIGNATURE: _________________________________________________________

                    (PATIENT / LEGAL REPRESENTATIVE)

DATE: ___________________________   TIME:  ________  am / pm

If signed by someone other than the patient, state your legal relationship to the patient:  _________________________________________________________________________

 

 

 

About Us  ||  Job Opportunities  ||  Services  ||  Physicians  ||  Foundation  ||  News & Features  ||  auxiliary  || CRMC Home || Contact Us || Privacy Practices

� 2005 - Colusa Regional Medical Center