Medical Records Release Form - North Coast Family Medical Group printable pdf download

Authorization for Use or Disclosure of Protected Health Information

North Coast Family Medical Group, Inc.

477 N. El Camino Real, Suite A306, Encinitas, CA 92024

(760) 942-0118 Phone

(760) 942-5319 Fax

As required by the Health Information Portability and Accountability Act (“HIPAA”) of 1996 and California law,

North Coast Family Medical Group, Inc. may not use or disclose your individually identifiable health information

except as provided in our Notice of Privacy Practices without your authorization. Your completion of this form

means that you are giving your permission for the uses and disclosure described below. Please be aware that

once your information leaves North Coast Family Medical Group, Inc., we will no longer be able to protect that

information and the recipients of your information may not be legally required to protect your information. I

hereby release North Coast Family Medical Group, Inc. from any and all legal liabilities that may arise from the

release of this information to the party listed below. This authorization is being requested of you to comply with

the terms of the Confidentiality of the Medical Information Act of 1981, Civil Code Section 56 et seq. and the

Health Insurance Portability and Accountability Act (HIPAA) of 2003.

I hereby authorize North Coast Family Medical Group, Inc. to obtain health information

concerning:

_____________________________________________

_________________________

Patient’s Name

Date of Birth

Transfer of Information from:

Information May be released to:

Physician/Facility Name, Address, phone/fax:

_____________________________________

North Coast Family Medical Group

_____________________________________

477 N. El Camino Real Ste. A306

__________________________________________

Encinitas, CA 92024

Health Information to be used or disclosed (check appropriate box(es):

 Pertinent Information (This is what most physicians need): Problem list, last 2 years

of Progress notes, immunizations, labs, radiology, diagnostic testing

Only dates of service from _____________ to _____________

Entire Medical Record

, including Web Portal Communication

Other (please specify):_______________________________________________________

Authorization to Release Statutorily Protected Information

I specifically authorize release of the following information (Initial if authorized)

Provider Name/Signature:

______ Psychiatric Progress Notes

_____________________________________

______ Therapy Notes

_____________________________________

______ Mental Health Labs

_____________________________________

______ HIV test results

_____________________________________

______ Alcohol/drug treatment information

_____________________________________

Medical Records Release Form - North Coast Family Medical Group

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