Authorization to Release Health Information

The following form is for established patients who want to share specific health information with a person or group outside of regular treatment activities. For example, you might use it to share certain details with a family member, attorney, or other third party.

Having an advocate during this time is encouraged

Authorization to Release Medical Information

Authorization to Release Medical Information

Authorization to Release Medical Information to Merced Comprehensive Cancer Center | El Portal Cancer Centers

Patient Name(Required)
MM slash DD slash YYYY
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 | El Portal Cancer Centers 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.
I authorize Merced Comprehensive Cancer Center | El Portal Cancer Centers to receive by mail or fax any any/or all medical information pertaining to my medical condition.
Name(Required)
Name
MM slash DD slash YYYY
Usually today's date
Clear Signature
Witness' Name(Required)
Clear Signature
MM slash DD slash YYYY

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