Medical Records Release Form - North Coast Family Medical Group


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
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


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