Release of Medical Records



Patient Name: _______________________________   

Date of Birth: ___________________

1.I authorize the use or disclosure of the above named individual’s health information as described below:

  1. 2.The following individual or organization is authorized to make the disclosure: 

  2. 3.



3.The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

oProblem list

oMedication list

oList of allergies

oImmunization record

oMost recent history and physical

oMost recent discharge summary

oLaboratory results                        from (date)________ to (date)________

oX-ray and imaging reports           from (date)________ to (date)________

oConsultation reports                     from (doctors’ names)_______________

oEntire record


4.I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services: and treatment for alcohol and drug abuse.

5.This information may be disclosed to and used by the following individual or organization:

Judy J. Davis M.D., F.A.A.P.

1095 E Warner Ave #102

Fresno, CA 93710

Phone # (559) 412-8184

Fax# (559) 438-1174

       6. I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to Dr. Davis’ staff. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition ________. If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

       7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not to sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524 I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have any questions about disclosure of my health, I can contact (Dr. Judy J. Davis)

___________________________________                                              ____________________________

Signature of Patient or Legal Representative                                             Date

___________________________________                                              ____________________________

If signed by Legal Representative, Relationship to Patient                        Signature of Witness  

Revised 10/16

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