HIPAA Medical Records Release Form (California)

State of California AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION All sections must be completed for the authorization to be valid. Use N/A if not applicable. Part I - Patient Information Last Name: Smith First Name: John Middle Name: A. Medical Reference Nº: 123456789 Date of Birth: 15 March 1980 Address: 123 Main Street City/State/ZIP: Los Angeles, CA 90001 Part II - Individual/Organization Authorized to Release PHI Name: Dr. Thomas Kelly Address: 456 Health Ave City/State/ZIP: Los Angeles, CA 90002 Part III - Individual/Organization Authorized by Signatory to Receive PHI Name: Jane Doe Relationship to Patient: Attorney Phone: (555) 123-4567 Address: 789 Legal Blvd, Los Angeles, CA 90003 Part IV - Authorization Expiration Event or Date Expiration Event: Conclusion of legal proceedings Expiration Date: 1 November 2025 Part V - Health Records to be Released - General I authorized the following records to be released: Medical, Dental Part VI - Health Records to be Released - Specific Blood Test Results – Signature: John Smith Date: 1 November 2024 X-Ray Reports – Signature: John Smith Date: 1 November 2024 Part VII - Purpose for the Release or Use of the Information Legal proceedings Part VIII - Authorization Information I understand the following: 1. I authorize the use or disclosure of the health information as described above for the purpose listed. I understand this authorization is voluntary. 2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party entered in Part II. The revocation will prevent further release of my health information from the date of receipt. 3. I am signing this authorization voluntarily and understand my health care treatment will not be affected if I do not sign this authorization. 4. The party entered in Part III is prohibited from re-disclosing the health information except with a written authorization or as specifically permitted by Cal. Code §56.10 or required by law (applies within California only). 5. If the party entered in Part III is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the released health information may no longer be protected by federal and state privacy regulations. 6. I have a right to receive a copy of this authorization. 7. Fees may be charged to cover the cost of releasing the health information. 8. I understand that my substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization. Part IX - Signature by or on Behalf of Patient Name of Patient (Print): John A. Smith Signature: John A. Smith Date: 1 November 2024