Fillable AUTHORIZATION TO DISCLOSE HEALTH INFORMATION AND OTHER RECORDS

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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION AND OTHER RECORDS

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AUTHORIZATION TO DISCLOSE HEALTH
INFORMATION AND OTHER RECORDS
HIPAA COMPLIANT PURSUANT TO Section Code 164.508
(Page 1 of 2)
Patient Name: _____________________________________________ Date of Birth: ____________________
Patient Address: ____________________________________________ SS#: ___________________________
Claim #: _____________________________ Medical Record # (if applicable): _________________________
I HEREBY GRANT PERMISSION TO AND AUTHORIZE THE USE OR DISCLOSURE OF THE ABOVE
NAMED INDIVIDUAL’S RECORDS AS DESCRIBED BELOW TO THE DESIGNATED ENTITIES:
And/or
PROFESSIONAL DOCUMENT SERVICES DBA PRODOC
875 Patriot Drive, Suite D
Moorpark, CA 93021
THE FOLLOWING INDIVIDUAL(S), MEDICAL PROVIDER(S), AND/OR ORGANIZATION(S) ARE
AUTHORIZED TO MAKE THE DISCLOSURE:
Name Address & Phone Number Date Range of
Treatment Requested
SPECIFY RECORDS: Check the box and initial below to specify which type of information to be disclosed
□ MEDICAL INFORMATION (All Medical reports including but not limited to SOAPE notes, all other
notes (typed or handwritten), records, charts, any letters, physical therapy records, lab reports and
outpatient reports and discharge summary
□ MEDICAL BILLING
□ X-RAYS/FILMS (MRI’s, CT-Scans, and Reports)
□ Personnel, Attendance, Employment, Payroll, Wage Records from an Employer or School
□ Insurance records, including all claims, itemized billing, correspondence, payments, and all documents
within the file
□ Drug/Alcohol Information ___________ (initial)
□ Psychiatric Information ____________ (initial)
□ Results of an HIV Blood Test ____________ (initial)
□ Other: __________________________________________________________________________
□ Exclusions: ______________________________________________________________________
The above information is being obtained to assist said authorized entities in evaluation of my claim for benefits
or damages. A copy or facsimile of this document shall be considered as effective and valid as the original.
REVOCATION: I understand that I have the right to revoke this authorization at any time. I understand that if
I revoke this Authorization I must do so in writing and present my written revocation to the health information
management department. I understand that revocation will not apply to my insurance company when the law
provides my insurer with the right to contest a claim under my policy.
DURATION: Unless otherwise revoked, this Authorization will expire on the following date, event or
condition: ______________________________________ OR in the absence of listed date, shall remain valid
for 1 year from date of signature.
The covered entity cannot require the patient to sign the authorization in order to receive treatment or payment
or to enroll or be eligible for benefits.
RE-DISCLOSURE: I understand that authorizing the disclosure of this health information is voluntary and that
I am entitled to a copy of this authorization and acknowledge receipt of a copy thereof. I can refuse to sign this
Authorization. I understand any disclosure of information carries with it the potential for an unauthorized re-
disclosure and the information may not be protected by federal confidentiality rules.
_____________________________________________________ ____________________
Signature of Patient or Legal Representative Date
_____________________________________________________
If Signed by Legal Rep., Relationship to Patient (please print)
“Insurance Code 1879.2 – Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.” “For your protection California law requires the following to
appear on this form.”
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AUTHORIZATION TO DISCLOSE HEALTH INFORMATION AND OTHER RECORDS

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Completed 25 March 2022

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