Authorization To Request Or Release Medical Information
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1Student Health Center - One Washington Square - San Jose, California 95192-0037 408/924-6150
Fax 408/924-7786
Accredited by Association for Ambulatory Health Care
AUTHORIZATION TO REQUEST OR RELEASE MEDICAL INFORMATION
PATIENT:
LAST NAME
FIRST NAME
I AUTHORIZE:
HEALTHCARE PROVIDER
ADDRESS
CITY
STATE
ZIP CODE
TO RELEASE TO:
NAME OF RECIPIENT
ADDRESS
CITY
STATE
ZIP CODE
I AM REQUESTING COPIES OF THE FOLLOWING INFORMATION FROM MY MEDICAL RECORD:
Complete Medical Records
Mental Health Records
HIV Records
X-ray/Laboratory Tests (specify):
Immunization (specify):
Physical Exam (date):
Gynecological including Pap Smears
Alcohol/Substance Abuse Records
Pap Smears
Records pertinent only to my illness on or about (date):
Other:
This authorization is for the purpose of
This authorization shall expire 60 days from the date below or on ________________________. It may be revoked in writing at
anytime.
I understand that I have a right to receive a copy of this authorization form upon my request.
YES
NO
Copy requested & received:
Patient's signature
Date:
Address:
Phone:
Birthdate:
Student ID # :
Witness:
Please allow up to 15 days to process your request. You will be contacted when copies are available for pickup. Payment is required upon
receipt. There is no charge for copies sent to another provider/facility.
FOR SJSU ONLY:
RECORDS REQUESTED OR RELEASED BY:
HEALTH RECORD TECHNICIAN
DATE
MedRec 09/2013
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