Authorization to Release Medical Information

In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPPA).

Authorization to Release Medical Information

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

Patient Name(Required)

First Last

Patient's Date of Birth(Required)

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.

Initial, if you consent(Required)

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)

First Last

Address - include city, state, zipcode

Relationship

Phone(Required)

Name

First Last

Address - include city, state, zipcode

Relationship

Phone

Any special instructions/considerations:

Authorization valid as of this date(Required)

Usually today's date

Patient's Signature(Required)

Witness' Name(Required)

First Last

Witness' Signature(Required)

Date(Required)

The California HIPAA release form enables patients to permit any person or 3rd party organization to have access to their personal health records. The HIPAA release form also optionally allows healthcare providers to share health information with each other. The California HIPAA release form can be revoked and/or reassigned at any time. The form is compliant with both local Californian regulations and federal regulations.

Thank you for taking the time to fill out this information.

Why do I need to have a medical release form?

A medical release form, also known as an authorization for release of protected health information (PHI), is a legally required document that allows a patient to authorize the release of their medical records to a specific person or entity. It ensures the patient’s privacy and adheres to regulations like HIPAA. The form needs to be signed by the patient (or their legal representative) and contains details about the specific information to be released, the purpose, and the recipient.

“Paperwork wouldn’t be so bad if it weren’t for all the paper. And the work. I have so much paperwork. I’m afraid my paperwork has paperwork.” — Darynda Jones