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: [insert patient's last name] (enter full legal surname exactly as provided; leave blank if not mentioned) First Name: [insert patient's first name] (enter full legal first name exactly as provided; leave blank if not mentioned) Middle Name: [insert patient's middle name] (enter full legal middle name if provided) Medical Reference Nº: [insert patient's medical record number] (include only if specifically mentioned) Date of Birth: [insert patient's date of birth] (use full date format; include only if explicitly stated) Address: [insert full street address of patient] (write full line address; include only if mentioned) City/State/ZIP: [insert patient's city, state and zip code] (enter all elements of the location; only include if provided) Part II - Individual/Organization Authorized to Release PHI Name: [insert full name of the individual or organization authorized to release information] (include only if specified) Address: [insert street address of releasing party] (write full line address; include only if explicitly mentioned) City/State/ZIP: [insert city, state, and zip of releasing party] (include in the same line format as the original) Part III - Individual/Organization Authorized by Signatory to Receive PHI Name: [insert full name of receiving individual or organization] (only include if mentioned) Relationship to Patient: [insert relationship of the receiving party to the patient] (e.g. spouse, attorney, etc.; include only if stated) Phone: [insert phone number of the recipient] (include full number if provided) Address: [insert recipient's address] (enter street address, city, state, and ZIP on one line as per original) Part IV - Authorization Expiration Event or Date Expiration Event: [insert the specific event that will terminate the authorization] (enter as a short description; only include if specified) Expiration Date: [insert date this authorization expires] (include in standard date format if provided; otherwise leave blank) Part V - Health Records to be Released - General I authorized the following records to be released: [insert general record types to be released] (write out the types of general records selected — e.g., medical, dental, or other — in line format; include only those explicitly mentioned. If 'Other' is selected, specify the content.) If Other, please specify: [insert custom type of health record] (only include if 'Other' is selected and specified) Part VI - Health Records to be Released - Specific [insert list of specific health record types to be released, along with corresponding signatures and dates] (list each selected category individually, using one line per item as follows: category name – Signature: [insert signature] Date: [insert date]. Only include categories mentioned and ensure signature and date are only included if documented.) Requests for psychotherapy notes require a separate authorization and may not be combined with any other request for health records. Part VII - Purpose for the Release or Use of the Information [insert selected purpose for release] (write out the stated reason: e.g. health care, legal, personal, or custom; use a single sentence format. If 'Other' is selected, include the specific reason provided.) 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): [insert patient's full name] (include only if explicitly mentioned; print format) Signature: [insert patient's signature] (include only if documented) Date: [insert signature date] (write full date format if provided) Name of person signing form if not patient: [insert name of proxy signer] (only include if the form was signed by someone else on behalf of the patient) Authority to sign on behalf of patient: [insert legal basis for proxy] (briefly describe the signer’s legal authority, e.g. legal guardian, power of attorney; include only if specified) Name of translator (if applicable): [insert translator's name] (only include if interpreter was involved) Signature of translator (if applicable): [insert translator's signature] (include only if provided) (Never come up with your own patient details, authorization purposes, records categories, or legal justification – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Maintain all formatting and paragraph structure exactly as per the source document.)