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California Authorization For Release of Health Information

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This form is provided by Health Information Management Services of Stanford Hospital and Clinics to authorize the disclosure or release of one person's protected health information.

California Authorization For Release of Health Information
California Authorization For Release of Health Information
15-79-1 (3/10)
STANFORD HOSPITAL and CLINICS (SHC)
LUCILE PACKARD CHILDREN’S HOSPITAL (LPCH)
AUTHORIZATION • RELEASE OF HEALTH
INFORMATION
Please send request to:
Stanford Hospital and Clinics
Health Information Management Services
450 Broadway, PAV-C, Room C14, MC5200
Redwood City, CA 94063
Phone: 650-723-5721 Fax 650-725-9821
Page 1 of 4
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
When you complete and sign this form, health information about you will be released as you
describe in the form. Please read each section carefully and complete the required sections
before signing. We encourage you to request a copy of your records and review them before
authorizing the release of the records to someone other than you. Please clearly and legibly
print all information when completing this form and sign on the last page.
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SECTION A: Please provide the name of the patient whose records are being requested for release.
Patient's name: Last:____________________________First:____________________ M:______
Date of birth:___________ Phone number:_____________ Medical Record number:___________
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SECTION B: Please describe the specific health information you would like released by completing
the appropriate information below. Certain specific health information requires a separate indication
from you in order for us to release that information, such as HIV test results, hereditary disorder test
results, family planning services and certain mental health information. If you would like this
information released, you will need to indicate separately in the boxes B.2, B.3, B.4, B.5 and B.6
below. You must both check the box and initial next to the box to authorize the release of the
information described after the box.
B.1: General Health Information R
elease (Please note: if you do not check any of the boxes in
Sections B.2, B.3, B.4, B.5 or B.6 below and there is information in your record as described in those
sections, the information described in those sections will not be included in the release if you simply
check the boxes in B.1). However, we will include mental health records, except as described in B.2.
_____ Check here and initial next to the box if you would like information related to specific
dates of service released and not the entire medical record.
Indicate dates of service
__________________________________________________________
_____ Check here and initial next to the box if you would like to further describe the health
information that you would like released, and please provide a description:
__________________
______________________________________________________________________________________
_____ Check here and initial next to the box if you would like your entire medical record
released.
_____ Check here and initial next to the box if you would like your Radiology Film or Radiology
Compact Disk (CD) released.
_____ Check here and initial next to the box if you would like your billing records or billing
information released.
California Authorization For Release of Health Information
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