Authorization For Use Or Disclosure Of Health Information Page 2

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MY RIGHTS
I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or
payment or eligibility for benefits.
I may inspect or obtain a copy of the health information that I am being asked to allow the use or
disclosure of.
I may revoke this authorization at any time, but I must do so in writing and submit it to:
Alvarado Hospital Medical Centre
Alvarado Hospital
ATTN: Medical Records
6655 Alvarado Road
San Diego, CA 92120
My revocation will take effect upon receipt, except to the extent that others have acted in reliance
upon this Authorization.
I have a right to receive a copy of this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such
re-disclosure is in some cases not protected by California law and may no longer be protected by
federal confidentiality law (HIPAA). However, California law prohibits the person receiving my health
information from making further disclosure of it unless another authorization for such disclosure is
obtained from me or unless such disclosure is specifically required or permitted by law.
Options of Electronic Format: According to HITECH section 13405(e) (1); 42 U.S.C. 17935 (e) (1), you
may have your electronic medical records transmitted to you or another entity in electronic format.
Please choose which type of format you would like the information to be delivered in and note the
receiving entity may not accept records in electronic format: F Burn to CD F Paper
SIGNATURE
Date: ________________________________
Time: ______________________ am/pm
Signature: ______________________________________________________________________________
(patient/representative/spouse/financially responsible party)
If signed by someone other than the patient, state your legal relationship to the patient. Licensed
Psychotherapist’s approval for geropsychiatric patient:
________________________________________________________________________________________
Witness: ________________________________________________________________________________
PATIENT I.D.
2 HIMROI
AUTHORIZATION FOR USE OR DISCLOSURE
OF HEALTH INFORMATION
Page 2 of 2
PHSI-280-014-AH (01/11)
PHSI-280-014-AH (01/11)
ORIGINAL - CHART
CANARY - PATIENT

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