Medical Records Release Form - North Coast Family Medical Group (Page 2 of 2) in pdf

_____________________________________________

_________________________

Patient’s Name

Date of Birth

Purpose of requested use or disclosure:

Continuing Care

Inspection of Record

Legal Matter

Insurance Claim

Personal Copy

Second Opinion

Other (please specify): _______________________________________________________

Expiration

This authorization expires (date) ____________. If no date is given, this authorization will

expire 6 months from the signature date.

My Rights

I may refuse to sign this Authorization. If I refuse to sign this Authorization, I should know that by law,

my health information cannot be released. My refusal will not affect my ability to obtain treatment or

payment or eligibility for benefits.

I may inspect or obtain a copy of the health information that I am being asked to allow the use or

disclosure of.

I may revoke this authorization at any time, but I must do so in writing and submit it to the following

address:

North Coast Family Medical Group

477 North El Camino Real, Suite A306

Encinitas, CA 92024

My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon

this Authorization.

I have a right to receive a copy of this Authorization.

Copy requested and received:

Yes

Initial:

Date:

Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-

disclosure is in some cases not protected by California law and may no longer be protected by federal

confidentiality law (HIPAA).

Signed: ____________________________________

Date:

Print Name: ______________________

_____

Telephone:

___________

If not signed by the patient, please indicate relationship:

Parent or guardian of minor patient –

I here by declare under penalty of perjury, that I am the natural or adoptive parent or legal

guardian of said child and there is no court order restricting or prohibiting my access to such

medical records.

Guardian or conservator of an incompetent patient or representative of deceased patient

Witness, Print Name: __________________________

Date:_______________

Witness Signature:____________________________________

Medical Records Release Form - North Coast Family Medical Group Page 2

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