Medical Information Release (Page 3 of 3) in pdf

UNIVERSITY OF CALIFORNIA, DAVIS

HEALTH SYSTEM

PATIENT NAME

AUTHORIZATION FOR RELEASE

MEDICAL RECORD #:

OF HEALTH INFORMATION

BIRTHDATE:

Page 2 of 2

The purpose of this release is for (check one or more):

At the request of the patient/patient representative

Other (state reason)

NOTICE

UCDHS and many other organizations and individuals such as physicians, hospitals and

health plans are required by law to keep your health information confidential. If you have

authorized the disclosure of your health information to someone who is not legally required

to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

YOUR RIGHTS

This Authorization to release health information is voluntary. Treatment, payment, enrollment

or eligibility for benefits may not be conditioned on signing this Authorization except in the

following cases: (1) to conduct research-related treatment, (2) to obtain information in

connection with eligibility or enrollment in a health plan, (3) to determine an entity’s

obligation to pay a claim, or (4) to create health information to provide to a third party.

This Authorization may be revoked at any time. The revocation must be in writing, signed by

you or your patient representative, and delivered to: Health Information Management

Department, UCDHS, 2315 Stockton Blvd., Building 12, Sacramento, California 95817.

The revocation will take effect when UCDHS receives it, except to the extent UCDHS or

others have already relied on it.

You are entitled to receive a copy of this Authorization.

EXPIRATION OF AUTHORIZATION

Unless otherwise revoked, this Authorization expires

(insert applicable date

or event). If no date is indicated, the Authorization will expire 12 months after the date of

my signing this form.

Print Name

Signature (Patient, Parent, Representative)

Date

Time

Relationship to Patient (Parent, Guardian,

Conservator, Patient Representative)

Witness (only if patient unable to sign) or

Interpreter

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION–P

71431-784 (1/09)

MR#06/92192

AGE

Medical Information Release Page 3

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