Cornerstone Health Centers — Anchored in Wellness

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Date

ID Verification (Type)

Patient Name *

ID Verified By

Birthdate

I authorize (Name of person or facility which has information) *

to release health information to:

Name of person or facility to receive information

Street Address

City, State, Zip Code

Fax / Phone

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)

Please specify the health information you authorize to be released:

Type(s) of health information

Date(s) of treatment

The following information will NOT be released unless you specifically authorize it by marking the relevant box(es) below:

Information pertaining to drug and alcohol abuse, diagnosis or treatment (42 C.F.R. §§2.34 and 2.35).

Information pertaining to mental health diagnosis or treatment (Welfare and Institutions Code §§5328, et seq.).

Release of HIV/AIDS test results (Health and Safety Code §120980(g)).

Release of genetic testing information (Health and Safety Code §124980(j)).

EXPIRATION OF AUTHORIZATION

Unless otherwise revoked, this Authorization expires on (insert applicable date or event). If no date is indicated, the Authorization will expire 12 months after the date of signing.

Expiration Date or Event

Print Name

Date

Time

Relationship to Patient (Parent, Guardian, Conservator, Patient Representative)

Signature (Patient, Parent, Guardian)

Sign with finger, stylus, or mouse

Requested Format

Paper

CD / Digital

NOTICE

Your healthcare provider and many other organizations are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

YOUR RIGHTS

This Authorization to release health information is voluntary. This Authorization may be revoked at any time in writing. You are entitled to receive a copy of this Authorization.

Practice Portal

Authorization Release Health Info Form

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION