AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION PURSUANT TO EVIDENCE CODE SECTION 1158 The undersigned authorizes the medical provider designated below to disclose specified medical records to a designated recipient. The medical provider shall not condition treatment, payment, enrollment, or eligibility for benefits on the submission of this authorization. | ||
Medical provider: ________________ Patient name: ________________ Medical record number: ________________ Date of birth: ________________ Address: ________________ Telephone number: ________________ Email: ________________ Recipient name: ________________ Recipient address: ________________ Recipient telephone number: ________________ Recipient email: ________________ Health information requested (check all that apply): ___Records dated from ________ to ________. ___Radiology records: ________ images or films ________ reports________digital/CD, if available. ___Laboratory results dated. ___Laboratory results regarding specific test(s) only (specify)________. ___All records. ___Records related to a specific injury, treatment, or other purpose (specify): ________________. Note: records may include information related to mental health, alcohol or drug use, and HIV or AIDS. However, treatment records from mental health and alcohol or drug departments and results of HIV tests will not be disclosed unless specifically requested (check all that apply): ___Mental health records. ___Alcohol or drug records. ___HIV test results. Method of delivery of requested records: ___Mail ___Pick up ___Electronic delivery, recipient email:________________ This authorization is effective for one year from the date of the signature unless a different date is specified here: ________________. This authorization may be revoked upon written request, but any revocation will not apply to information disclosed before receipt of the written request. A copy of this authorization is as valid as the original. The undersigned has the right to receive a copy of this authorization. Notice: Once the requested health information is disclosed, any disclosure of the information by the recipient may no longer be protected under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Patient signature*: ________________ Date: ________________ Print name: ________________ *If not signed by the patient, please indicate relationship to the patient (check one, if applicable): ___Parent or guardian of minor patient who could not have consented to health care. ___Guardian or conservator of an incompetent patient. ___Beneficiary or personal representative of deceased patient. |
Ca. Evid. Code § 1158