Authorization to Release Medical Information to Merced Comprehensive Cancer Center

Merced Comprehensive Cancer Center
3303 M Street, Merced CA 95348 Phone - (209) 726-3410 Fax - (209) 726-3371
In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPPA), in order for physician or staff of Merced Comprehensive Cancer Center to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your Medical condition, the law stipulates that these rules may be waived.
(initials) I authorize Merced Comprehensive Cancer Center to receive by mail or fax any or all medical information pertaining to my medical condition.*

(initials) I authorize Merced Comprehensive Cancer Center to receive by mail or fax any or all medical information pertaining to my medical condition.
Date of Birth*
MM slash DD slash YYYY
Patient Name*
First Middle Last
Date*
MM slash DD slash YYYY
Patient Signature*
Witness*
Date*
MM slash DD slash YYYY
Witness Signature*