Urgent Medical Record Request Form

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.

To better serve you for your upcoming appointment, we will request the following information from your previous Primary Care Provider upon completion of this form:

• Last Office or Consult Notes
• Last Recorded Lab Results

Your Protected Health Information will be released to:

Edinger Medical Group – Senior Care Department

9900 Talbert Ave, Suite 301-302

Fountain Valley, CA 92708

Direct Dial: 714-965-2558

Dedicated Fax: 714-975-5851

Disclaimer: 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.

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 a 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 receive a copy of the signed Authorization form.

Right to Revoke This Authorization: A patient has the right to revoke this 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:

1. the patient is incompetent
2. the patient is disabled and cannot sign the form
3. 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 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:

1. alcohol or other drug abuse treatment: age 12 or older
2. mental health treatment: age 12 or older may consent to release of records without parental consent
3. HIV test results: age 12 or older
4. emancipated minors who are married or in the military

Fees for Records: Copies of a patient’s medical records 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.