Authorization To Disclose Health Information And Other Records Hipaa Compliant Form - California

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AUTHORIZATION TO DISCLOSE HEALTH
INFORMATION AND OTHER RECORDS
HIPAA COMPLIANT PURSUANT TO Section Code 164.508
(Page 1 of 2)
Patient Name: _____________________________________________ Date of Birth: ____________________
Patient Address: ____________________________________________ SS#: ___________________________
Claim #: _____________________________ Medical Record # (if applicable): _________________________
I HEREBY GRANT PERMISSION TO AND AUTHORIZE THE USE OR DISCLOSURE OF THE ABOVE
NAMED INDIVIDUAL’S RECORDS AS DESCRIBED BELOW TO THE DESIGNATED ENTITIES:
And/or
PROFESSIONAL DOCUMENT SERVICES DBA PRODOC
875 Patriot Drive, Suite D
Moorpark, CA 93021
THE FOLLOWING INDIVIDUAL(S), MEDICAL PROVIDER(S), AND/OR ORGANIZATION(S) ARE
AUTHORIZED TO MAKE THE DISCLOSURE:
Name
Address & Phone Number
Date Range of
Treatment Requested
SPECIFY RECORDS: Check the box and initial below to specify which type of information to be disclosed
□
MEDICAL INFORMATION (All Medical reports including but not limited to SOAPE notes, all other
notes (typed or handwritten), records, charts, any letters, physical therapy records, lab reports and
outpatient reports and discharge summary
□
MEDICAL BILLING
□
X-RAYS/FILMS (MRI’s, CT-Scans, and Reports)
□
Personnel, Attendance, Employment, Payroll, Wage Records from an Employer or School
□
Insurance records, including all claims, itemized billing, correspondence, payments, and all documents
within the file

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