Fillable Note: Fees may apply to certain requests Walnut

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Note: Fees may apply to certain requests Walnut

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PATIENT LABEL
PRINT NAME:
DOB:
MRI:
3ROI
Note: Fees may apply to certain requests
RELS-36 (4/29/21)
ID VERIFICATION (TYPE)
ID VERIFIED BY
AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
WHITE - CHART YELLOW - PATIENT
Use or Disclosure: I hereby authorize (select appropriate JMH entity or location below):
Walnut Creek Medical Center Concord Medical Center
Behavioral Health Center
Physician Network Practice Ofce (specify practice location below):
______________________________________________________________________________
Other (specify): __________________________________________________________________
Expiration: This authorization expires on (date):_________________________. If blank, authorization
will expire in 1 year from date of signature.
Signature:
________________________________ Date: ______Time: ____ Phone: _____________
Print Patient Name: ____________________________________Date of Birth: __________________
Print Requestor Name
(if other than patient, documentation may be required):
______________________
Relationship to Patient: Legal Representative Spouse
Parent (Minor consent may be required) Guardian Conservator  Beneciary
To release health information to:
______________________________________________________
Name of person or facility to receive health information (full address):
______________________________________________________
Street address:
______________________________________________________
City, State, Zip Code:
______________________________________________________
Email:
_________________________________________________
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 (state reason) _______
_______________________
Limitations, if any: ___________
__________________________
The following information will not be released unless you specically authorize it by marking the
relevant box(es) below:
_______ Information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R. Part 2).
_______ Information pertaining to mental health diagnosis or treatment (Welfare and Institutions Code
§5328, et seq.)
_______ Release of HIV test results (Health and Safety Code §120980(g)).
_______ Release of genetic testing information (Health and Safety Code §124980(j)).
Requested Format:
Paper (charges apply) CD (charges apply) Encrypted Email
Other (specify): ____________________________________________________
Delivery Preference:
Mail Pickup Encrypted Email MyChart Patient Portal Other: ________
Please specify the health information you authorize to be released.
Hospital Records Outpatient Records Imaging Reports Imaging Films Lab
Procedure/Operative Reports Billing Immunizations Other: __________________________
Date(s) of treatment: __________________________________________________________________
initial
initial
initial
initial
Additional Receiving Parties (Behavioral Requests Only):
Psychiatrist:_____________ Therapist_____________ PCP:_____________ Other: ______________
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Authorization for Use or Disclosure of Protected Health Information
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. Please mail completed form to the
appropriate John Muir Health entity where treatment or services were rendered. To inquire about the status
of your request, please call the phone number of the appropriate entity Health Information Management
department listed below.
My Rights
• 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 refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment
or eligibility for benets, except in the following circumstances:
o When the authorization is for eligibility, enrollment, underwriting or risk rating determination.
o When the sole purpose for creating the requested protected health information is to disclose to a
third party.
o For research related treatment.
• I may revoke this authorization at any time. My revocation must be in writing, signed by me or an authorized
legal representative, and delivered to the appropriate John Muir Health entity and location where the
original authorization request was submitted (see above). My revocation will take effect upon receipt,
except to the extent those 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 redisclosed by the recipient. Such redisclosure
in some cases is not prohibited by California law and may no longer be protected by federal condentiality
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 permitted or required by law.
Health Information Management (him@johnmuirhealth.com)
5003 Commercial Circle, Concord CA 94520
(925) 947-5373 FAX: (925) 947-3235
Health Information Management (him@johnmuirhealth.com)
5003 Commercial Circle, Concord CA 94520
(925) 947-5373 FAX: (925) 947-3235
Health Information Management (him@johnmuirhealth.com)
5003 Commercial Circle, Concord CA 94520
(925) 674-4105 FAX: (925) 692-5741
Walnut Creek Medical Center
1601 Ygnacio Valley Road
Walnut Creek, CA 94598
Physician Network Practices
Behavioral Health Center
2740 Grant Street
Concord, CA 94520
Location of Treatment/Services
Concord Medical Center
2540 East Street
Concord, CA 94520 94520
Where to Submit Request
Health Information Management (him@johnmuirhealth.com)
5003 Commercial Circle, Concord CA 94520
(925) 947-5373 FAX: (925) 947-3235
RELS-36 (4/29/21)
AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
WHITE - CHART YELLOW - PATIENT
ID VERIFICATION (TYPE)
ID VERIFIED BY
PATIENT LABEL
PRINT NAME:
DOB:
MRI:
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Note: Fees may apply to certain requests Walnut

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Completed 28 January 2022

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