Release of Information

Step 01

Identify the people or organizations

Enter the person or facility that currently holds the information and the person or facility authorized to receive it.

I authorize — name of person or facility that has the informationTo release health information to — name of person or facility receiving the information

Recipient street addressCityStateZIP code

Exchange authorization

I authorize exchange of information between the people or organizations listed above.

Step 02

Specify the purpose and records

The purpose of this release is for

Continuity of care or discharge planningBilling and payment of billAt the request of the patient/patient representativeOther

If other, state the reasonIf other, specify the type of records

Delivery method

MailPick-upOnline Portal (Medical Records Only)

Step 03

Specially protected information

The following information will not be released unless you specifically authorize it by selecting the applicable item.

I specifically authorize release of

Information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R. §§2.34 and 2.35)Information pertaining to mental health diagnosis or treatment (Welfare and Institutions Code §§5328, et seq.)HIV/AIDS test results (Health and Safety Code §120980(g))Genetic testing information (Health and Safety Code §124980(j))

Expiration of authorization

Unless revoked earlier, this authorization expires on the date or event entered below. If no date or event is entered, it expires 12 months after the date the form is signed.

Expiration date or event

Step 04

Review your rights and complete the authorization

Print or save the completed form, then sign through an approved process or on paper.

Print nameDateTimeRelationship to patientParent, guardian, conservator, or patient representativeSignature — complete after printing or through an approved signature processTyping here does not create a secure electronic signature.

Notice

The Medical Partners Group (TMPG) is required by law to keep your PHI (protected health information) confidential. If you have authorized disclosure of your PHI to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

Your rights

This Authorization to release health information is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases: (1) to conduct research-related treatment, (2) to obtain information in connection with eligibility or enrollment in a health plan, (3) to determine an entity’s obligation to pay a claim, or (4) to create health information to provide to a third party.

Nothing is submitted online

Use Review & Print / Save PDF below. Deliver the signed authorization using a secure method approved by the practice.

Authorization for Release of Health Information

Identify the people or organizations