AUTHORIZATION TO RELEASE HOSPITAL RECORD INFORMATION
Authorization with an original signature* of an officer of the hospital is required to
release hospital confidential data to persons not associated with the hospital.
Please release hospital confidential data to:
Officer authorizing release of hospital confidential data:
*A FAXed document does not satisfy the criteria for an original signature.
Please complete, sign, and mail to:
Department of Health Care Services
Disproportionate Share Hospital Unit
1501 Capitol Avenue, MS 4506
P.O. Box 997419
Sacramento, CA 95899-7419