AUTHORIZATION
FOR USE
AND DISCLOSURE
Failure to complete all sections of this form may invalidate this request.
Patient/Participant/Client Information
Patient’s Last Name: DOB:
Phone Number:
Patient’s First Name:
E-Mail Address:
Entity/Person To Disclose PHI
Entity/Person To Receive PHI
Name:
Name:
Address:
Address:
City:
Zip:
City:
Zip:
Phone:
Fax:
Phone:
Fax:
PURPOSE OF INFORMATION TO BE RELEASED:
Personal Use Changing Physicians Legal Investigation
Continuity of Care Insurance Eligibility/Benefits Other: ____________
DATES OF SERVICE:
From: _____/______/______ To: _____/______/______ OR All Dates of Service
TYPE OF INFORMATION TO BE RELEASED:
Clinic Records Immunization History Laboratory Results
Dental Records Billing Records Radiology Results/Images
OB/GYN Records HIV Test Results Reproductive Health
STD Lab Results Entire Medical Record Other: _____________
METHOD FOR PROCESSING RELEASE:
Mail to Patient Address Listed Above MyAltaMed Patient Portal
Other (Please Specify):____________ E-Copy Encrypted (CD, Flash Drive)
Patient/Designee/Legal Representative to Pick Up
If picked up by someone other than patient write individual name: ________________
EXPIRATION: I understand that this authorization will be in effect until:
Expiration Date: _____/______/______ or Event: __________________________.
If there is no expiration date this authorization will expire 6 months after the date of
signature.
AUTHORIZATION
FOR USE
AND DISCLOSURE
RESTRICTIONS: I understand that the information released with this authorization
may be subject to re-disclosure by the recipient and may no longer be protected by
federal or state law. California law prohibits the requestor from making further
disclosure of your health information unless the requestor obtains another
authorization from you or unless such disclosure is specifically required or permitted by
law.
PATIENT RIGHTS: I understand I have a right to receive a copy of this authorization.
AltaMed will not condition my treatment, payment, enrollment in a health plan, or
eligibility for benefits on whether I provide authorization for the requested release,
unless as otherwise specifically required or permitted by law.
CANCELLATION of AUTHORIZATION: You may cancel this authorization at any
time. If you choose to do so, it must be done in writing and signed by you or your legal
representative and sent to the following address: AltaMed Health Services, Attn:
Health Information Management Director, 2040 Camfield Avenue, Commerce, CA
90040. The HIM Director may be reached at 323-622-2444 for authorization-related
questions, concerns, or complaints.
If signed by someone other than patient, indicate relationship:
Parent/Legal Guardian Personal/Legal Representative
Caregiver Durable Power of Attorney
Other (Please Specify):_____________
AUTHORIZATION:
__________________________ _____/______/______
Patient Printed Name Date
__________________________
_____/______/______
Signature Date
