Form 071-61 - Consumer Comp[liant Form - Medical Board Of California Page 4

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BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY - Department of Consumer Affairs
EDMUND G. BROWN JR., Governor
MEDICAL BOARD OF CALIFORNIA
Central Complaint Unit
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Patient Name (Last, First, Middle)
Date of Birth
Medical Record Number (If applicable)
Date of Death (If applicable)
Control Number
Social Security Number (Optional)
I, the undersigned hereby authorize:
Physician/Facility:
Address:
City/State/Zip Code:
Phone Number(s):
Treatment Date(s):
to disclose medical records in the course of my diagnosis and treatment to the Medical Board of California,
Enforcement Program, a healthcare oversight agency. This disclosure of records authorized herein is required
for official use, including investigation and possible administrative and/or criminal proceedings regarding any
violations of the laws of the State of California. This authorization shall remain valid for three years from the
date of signature. A copy of this authorization shall be as valid as the original. I understand that I have a
right to receive a copy of this authorization if requested by me. I understand that I have the right to revoke this
authorization by sending written notification to the Medical Board of California at the address below. My
written revocation will be effective upon receipt by the Medical Board of California but will not be effective to
the extent that such persons have acted in reliance upon this Authorization. I understand that the recipient of
my information is not a health plan or health care provider and the released information may no longer be
protected by federal privacy regulations.
Patient Signature:
Date:
or Legal Representative:
Date:
Relationship
NOTE: Failure by a physician, podiatrist or health care provider to provide the requested records within 15 days, or a health care facility in 30 days,
of receipt of this request and authorization may constitute a violation of Section 2225.5 of the Medical Practice Act and may result in further action
by the Board. This release is compliant with the requirements of HIPAA and Civil Code Section 56.11.
Enf-27a (Revised 5/14)
2005 Evergreen Street, Suite 1200, Sacramento, CA 95815-3831 (916) 263-2528 FAX: (916) 263-2435

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