Medical Records Release Form

Authorization for Use or Disclosure of Health Information

Please indicate whether you would like your protected health information to be released to or from Edinger Medical Group. Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with California and Federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this Authorization.
Patient Information
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
E-mail Address

Confirmation Emailexample@example.com
Please select one of the medical records release options below:*

I would like Edinger Medical Group to send my medical records to the designated physician/facility or mailed to my home address.I would like ANOTHER designated physician/facility to send my medical records to Edinger Medical Group.
Authorization for Edinger Medical Group to Release Protected Health Information
Where would you like Edinger Medical Group to send your protected health information?*

I would like Edinger Medical Group to send my medical records to the designated physician/facility.I would like Edinger Medical Group to mail my medical records to me (my home address).
I authorize the release of my health information FROM (organization that will RELEASE your information)

Edinger Medical Group
9900 Talbert Avenue, Suites 301-302
Fountain Valley, CA 92708

to be released to the following PHYSICIAN/FACILITY:
Physician/Facility that will RECEIVE your information*
Fax Number*
Please enter a valid phone number.
Address of physician or facility that will RECEIVE your information*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
I authorize the release of my health information FROM (organization that will RELEASE your information)

Edinger Medical Group
9900 Talbert Avenue, Suites 301-302
Fountain Valley, CA 92708

to be mailed to the following HOME ADDRESS:
Your HOME ADDRESS that will RECEIVE your information:*

Street Address

Street Address Line 2

CityState

Zip Code
Authorization for Designated Physician/Facility (NOT EMG) to Release Protected Health Information
I authorize the release of my health information FROM:
Designated Physician/Facility (NOT EMG) that will RELEASE your information*
Fax Number*
Please enter a valid phone number.
Address of physician/facility (NOT EMG) that will RELEASE your information*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
To be released TO the following recipient (organization that will RECEIVE your information):

Edinger Medical Group
9900 Talbert Avenue, Suites 301-302
Fountain Valley, CA 92708
Health Information to be Released for the Following Dates
Dates/Time Period of Health Information*
INVALID if NOT filled in
Part A: Health Information to be Released*

OB/GYN RecordsSpecific VisitsImmunization RecordsLab ReportsX-ray ReportsX-ray FilmsBilling RecordsOther
Part B: In compliance with California Statutes, which require special permission to release otherwise privileged information, please INITIAL next to the records that you want released: (separate specific authorization required)
Mental Health
Drug Abuse
Alcohol Abuse
HIV/AIDS Testing
Health Information Release Authorization
By initialing here, I hereby authorize the use and/or disclosure of my health information as described in Part A and/or Part B.*
Purpose or Need for Request
Primary reason for requesting medical records:*

Seeking a new Primary Care Physician at Edinger Medical GroupLeaving Edinger Medical Group to seek a new Primary Care PhysicianMoved out of areaInsurance changeOther
This authorization will expire on the date below. If I do not indicate a date, this authorization will expire one (1) year from the date of my signature.

MonthDayYear
Date
Signature*

Clear
Signer's Name*

First NameLast Name
Was this signed by someone other than the patient?*

YesNo
Please state your legal relationship to the patient:*
If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may be disclosed and may no longer be protected. California law prohibits recipients of your health information from redisclosing such information except with your written authorization or as specifically required or permitted by law.
Additional Information Regarding Release of Health Information
Edinger Medical Group recognizes the patient's right of confidentiality of their health information under federal privacy regulations and California law. The patient should be aware of the following information when requesting or releasing health information.

Right to Refuse to Sign this Authorization: This authorization is voluntary. Refusal to sign will not affect the patient's ability to receive treatment or payment of claims.

Right to Inspect or Receive a Copy of Health Information to be Used or Disclosed: A patient has the right to inspect or obtain a copy of the health information they have authorized to be used or disclosed by signing this Authorization form.

Right to Receive a Copy of this Authorization: A patient has the right to revoke his authorization at any time by giving written notice of revocation to the Privacy Officer. Revocation of this authorization WILL NOT affect any action taken in reliance of this authorization before receipt of the written notice of revocation.

Multiple Releases of Information: A patient may request multiple releases of the information stated on the Authorization form. However, all releases based on this form are limited to records dated up to and including the date of the patient's signature. A new authorization is necessary for release of information for care provided after the date of the patient's signature, UNLESS the authorization specifically states that SPECIFIC RECORDS that will be generated in the future may be released, for example, "future records of a specific test" or "future records of specific clinic appointment."

Who May Sign this Authorization
1. Generally, all patients 18 years of age and older must sign for release of their own health information unless the following conditions apply:
  - The patient is incompetent
  - The patient is disabled and cannot sign the form
  - The patient is deceased (a surviving spouse or personal representative of the estate may sign. If there is no surviving spouse or representative, then an adult member of the immediate family may sign)
  IMPORTANT: With very few exceptions, if the patient is age 18 or older, parents' signatures ARE NOT acceptable.
2. All persons signing for release of health information on behalf of the patient must state their relationship to the patient and provide legal proof of legal authority of their capacity to act for the patient.
3. Minors: Patients less than 18 years of age must sign for release of health information in the following cases:
  - Alcohol or other drug related abuse treatment: age 12 or older
  - Mental health treatment: age 12 or older may consent to release of records without parental consent
  - HIV test results: age 12 or older
  - Emancipate minors who are married or in the military
Fees for Records: Copies of a patient's medical record sent directly to another physician or medical facility will be made generally at no charge; however, if many requests are made, a copying fee may be applied as allowed by California law.
Edinger Medical Group Medical Records
Email: medicalrecords@edingermedicalgroup.com
Fax: 714-965-2593
Should be Empty:

Authorization for Use or Disclosure of Health Information

Patient Information

Authorization for Edinger Medical Group to Release Protected Health Information

Authorization for Designated Physician/Facility (NOT EMG) to Release Protected Health Information

Health Information to be Released for the Following Dates

Health Information Release Authorization

Purpose or Need for Request

Additional Information Regarding Release of Health Information