Authorization For Use And Disclosure Of Health Information (Page 2 of 2) in pdf

Authorization For Use And Disclosure Of Health Information Page 2

I specifically authorize release of the following information:

[ ] HIV test results ___ (initial)

[ ] Substance abuse ___ (initial)

[ ] Mental Health ___ (initial)

[ ] Genetic testing ___ (initial)

EXPIRATION: This authorization shall become effective immediately and shall remain in

effect for one year from the date signed unless a different date is specified here:

________________________

RESTRICTIONS: California law prohibits the recipient from making further disclosure of

your health information unless the recipient obtains another authorization from you or

unless the disclosure is required or permitted by law. This protection does not extend to

recipients outside the state of California.

YOUR RIGHTS:

 I may refuse to sign this authorization and my refusal will not affect my ability to obtain

treatment or payment.

 I may revoke this authorization at any time. My revocation must be in writing, signed by

me or on my behalf, and delivered to this address:

Sutter Medical Foundation

Attn: HIPAA Privacy Officer

1014 N. Market Blvd., Suite 10, Sacramento, CA 95834

 My revocation will be effective upon receipt, but will have no impact on uses or

disclosures made while my authorization was valid.

 I have a right to receive a copy of this authorization (required if authorization is

requested for the provider’s use or disclosure of health information).

 I may inspect and obtain a copy of the health information of which I am authorizing the

use or disclosure.

If this box [ ] is checked the facility listed above will receive compensation for the use or

disclosure of my health information.

SIGNATURE: _______________________________ Date: __________ Time: _________

(Patient/Legal Representative)

If signed by other than patient, print name and relationship:

Name: __________________________________ Relationship: _____________________

There may be fees incurred for this service.

Office Use Only

Identification verified by (name):_______________________________

Verified by (method): [ ] Photo ID

[ ] Matching Signature [ ] Other _________________

Mail or Fax Completed Form to: 1014 N. Market Blvd., Suite 20, Sacramento, CA 95834

Fax #: 1-855-421-9633

Revised 10/02/2013

Authorization For Use And Disclosure Of Health Information Page 2