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PATIENT I.D.
AUTHORIZATION FOR
USE OR DISCLOSURE
OF HEALTH
INFORMATION
Page 1 of 2
ORIGINAL - CHART CANARY - PATIENT
Completion of this document authorizes the disclosure and/or use of health information, about you.
Failure to provide all information requested may invalidate this Authorization.
Name of Patient: _________________________________________________________________________
Date of Birth: ______________________________ SSN: ________________________________________
Patient Address: _________________________________________________________________________
City: ___________________________________________________ State: __________ Zip: ____________
Phone #: ________________________________________________________________________________
USE AND DISCLOSURE OF HEALTH INFORMATION
I hereby authorize ________________________________________________________________________
to release to: ________________________ Covering the period of healthcare from _______ to _____
Phone #: ________________________________________ Fax: ___________________________________
(Persons/Organizations authorized to receive the information) (Address - street, city, state, zip code
and/or fax number)
The following information:
a. ! All health information pertaining to my medical history, mental or physical condition and
treatment received. - OR
! Only the following records or types of health information (including any dates):
! Discharge Summary ! Consultation(s) ! All pertinent Lab / X-rays / EKG
! History and Physical ! Operative Report ! Other: ______________________
! Rehab ! ER
b. I specifically authorize release of the following information (initial as appropriate):
______ Mental health treatment information ______ STD
______ HIV test results ______ Sexual Assault
______ Alcohol/drug treatment information ______ Child Abuse/Neglect
______ Outpatient psychotherapy notes
PURPOSE
Purpose of requested use or disclosure: ! patient request; OR ! other:
________________________________________________________________________________________
________________________________________________________________________________________
EXPIRATION
This authorization expires on: _____________________________________________________________
PLEASE CONTINUE ON NEXT PAGE
2 HIMROI
PHSI-280-014-AH (01/11)
PATIENT I.D.
AUTHORIZATION FOR
USE OR DISCLOSURE
OF HEALTH
INFORMATION
Page 2 of 2
2 HIMROI
ORIGINAL - CHART CANARY - PATIENT
MY RIGHTS
I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or
payment or eligibility for benefits.
I may inspect or obtain a copy of the health information that I am being asked to allow the use or
disclosure of.
I may revoke this authorization at any time, but I must do so in writing and submit it to:
Alvarado Hospital
ATTN: Medical Records
6655 Alvarado Road
San Diego, CA 92120
My revocation will take effect upon receipt, except to the extent that others have acted in reliance
upon this Authorization.
I have a right to receive a copy of this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such
re-disclosure is in some cases not protected by California law and may no longer be protected by
federal confidentiality law (HIPAA). However, California law prohibits the person receiving my health
information from making further disclosure of it unless another authorization for such disclosure is
obtained from me or unless such disclosure is specifically required or permitted by law.
Options of Electronic Format: According to HITECH section 13405(e) (1); 42 U.S.C. 17935 (e) (1), you
may have your electronic medical records transmitted to you or another entity in electronic format.
Please choose which type of format you would like the information to be delivered in and note the
receiving entity may not accept records in electronic format: Burn to CD Paper
SIGNATURE
Date:
________________________________ Time: ______________________ am/pm
Signature:
______________________________________________________________________________
(patient/representative/spouse/financially responsible party)
If signed by someone other than the patient, state your legal relationship to the patient. Licensed
Psychotherapist’s approval for geropsychiatric patient:
________________________________________________________________________________________
Witness:
________________________________________________________________________________
PHSI-280-014-AH (01/11)
Alvarado Hospital Medical Centre
PHSI-280-014-AH (01/11)
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Completed 16 August 2021

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