Release of Information Form 7 Authorization for Release of Health Information Click here to download the PDF version of this form or fill it out electronically below "*" indicates required fields I AuthorizeName of person or facility which has information*to release health information to:Name of person or facility to receive health information*Check this box to authorize exchange between the persons/organizations listed above* Check this box to authorize exchange between the persons/organizations listed above*The purpose of this release is for (check one or more):* Continuity of care or discharge planning Billing and payment of bill At the request of the patient/patient representative Other Other: State Reason*Please specify the health information you authorize to be released and check all services that apply:* All Medical Records Emergency Room Visits Immunization Records Clinic or Office Visits Entire Hospital Record (OB)GYN Records Radiology Images Laboratory & Pathology Reports Other Other Records (not listed above, please specify type):*Delivery Method (please select one):* Mail Pick-up Online Portal (Medical Records Only) The following information will not be released unless you specifically authorize it. Please mark box(es) below accordingly:* 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.) Release of HIV/AIDS test results (Health and Safety Code §120980(g)) Release of genetic testing information (Health and Safety Code §124980(j)). EXPIRATION OF AUTHORIZATIONUnless otherwise revoked, this Authorization expires at the above (insert applicable date or event). If no date is indicated, the Authorization will expire 12 months after the date of my signing this form. Print Name*Relationship to Patient(Parent, Guardian, Conservator, Patient Representative) Date* MM slash DD slash YYYY Time* Hours : Minutes AM PM AM/PM NOTICE The Medical Partners Group (TMPG) is required by law to keep your PHI (protected health information) confidential. If you have authorized the disclosure of your PHI 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.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
