1065 Bucks Lake Road | Quincy, CA 95971 | Phone: (530) 283-2121 | Fax: (530) 283-7197 | www.pdh.org (8/20)
Authorization for Release of
COVID-19 Related Records
The following form authorizes the medical provider designated below to disclose or
discuss specified medical records or information to a designated recipient.
Patient Name:
Date of Birth:
Requesting Facility Name
Authorized Recipient Name
570 Golden Eagle Ave, Quincy CA 95971
Health Information Requested (check all that apply)
COVID-19 related records:
☒
☐ Visit Records
☐ Imaging Results
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 (Student) signature*: _________________________________________ Date: ____________________
Print name: ____________________________________________________________
*If not signed by the patient/student, please indicate relationship to the patient:
__________________________________________________________________________________________
(Parent, Guardian, Conservator or Legal Representative)
For Internal Use Only
Date of Request: ___________________________ Contact Person:______________________________________
click to sign
signature
click to edit
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