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.
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.