(Name of Provider) to release information from my medical record a
(Name of Provider) to release information from my medical record a
(Name of Provider) to release information from my medical record a
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Authorization for Release <strong>of</strong> Information <strong>to</strong> AHP<br />
Patient <strong>Name</strong>: __________________________________________________________<br />
Last First MI Maiden or Other <strong>Name</strong><br />
Date <strong>of</strong> Birth: ___-___-____ Social Security Number: ____-___-______<br />
Address: ______________________________________________________________<br />
Street City State Zip<br />
Day Phone: ______-______-______<br />
Evening Phone: ______-______-______<br />
I hereby authorize __________________________________________<br />
(<strong>Name</strong> <strong>of</strong> <strong>Provider</strong>) <strong>to</strong> <strong>release</strong> <strong>information</strong> <strong>from</strong> <strong>my</strong> <strong>medical</strong> <strong>record</strong> as<br />
indicated below <strong>to</strong>: ARCH HEALTH PARTNERS<br />
AHP/Poway, 15611 Pomerado Road, Suite 400, Poway, CA 92064<br />
Phone: 858-675-3199 FAX: 858-673-5187<br />
AHP/Ramona, 1236 Main Street, Ramona, CA 92065<br />
Phone: 760-789-5160 FAX: 760-789-6316<br />
AHP/ENT Specialty Center, 15525 Pomerado Road, Suite C-1, Poway, CA 92064<br />
Phone: 858-485-7870 FAX: 858-485-6473<br />
INFORMATION TO BE RELEASED:<br />
His<strong>to</strong>ry and Physical Exam<br />
Progress Notes<br />
Lab Reports<br />
X-Rays<br />
Other: _________________<br />
DATES TO BE RELEASED:<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
______________________________<br />
PURPOSE OF DISCLOSURE:<br />
Changing Physicians Consultation/Second Opinion Legal<br />
Continuation <strong>of</strong> Care Workers Compensation Insurance<br />
School<br />
Other (please specify): ________________________<br />
HOW WOULD YOU LIKE YOUR INFORMATION TO BE PROVIDED?<br />
Paper<br />
Electronically on CD<br />
Page 1 <strong>of</strong> 2<br />
PP933B/Autho for Release form US/4/08/bc
Authorization for Release <strong>of</strong> Information <strong>to</strong> AHP<br />
1. I understand that this authorization will expire on _______________<br />
(Print the Date you would like this Form <strong>to</strong> expire, allowing at least 30<br />
days for us <strong>to</strong> gather, copy, and send your <strong>information</strong>. If blank,<br />
authorization will expire one (1) year <strong>from</strong> date <strong>of</strong> signature.)<br />
2. I understand that I may cancel this authorization at any time. To cancel<br />
this authorization, I must notify Arch Health Partners in writing. This<br />
authorization will be cancelled once Arch Health Partners has received<br />
<strong>my</strong> written notice <strong>to</strong> cancel. The exception <strong>to</strong> this would be if <strong>my</strong><br />
<strong>information</strong> has already been <strong>release</strong>d.<br />
3. I understand that if I am being requested <strong>to</strong> <strong>release</strong> this <strong>information</strong> by<br />
__________________ (Print <strong>Name</strong> <strong>of</strong> <strong>Provider</strong>) for the purpose <strong>of</strong><br />
_______________________________________.<br />
a. I understand I may see and copy the <strong>information</strong> described on this<br />
form if I ask for it, and that I will get a copy <strong>of</strong> this form after I sign it.<br />
b. I have been informed that Arch Health Partners will not receive<br />
financial or in-kind compensation in exchange for using or disclosing<br />
<strong>my</strong> health <strong>information</strong> as described above.<br />
c. I understand that treatment, payment, continued enrollment in a<br />
health plan or eligibility for benefits will not be conditioned upon <strong>my</strong><br />
authorization.<br />
4. I understand that in compliance with California statute, I will pay a fee <strong>of</strong><br />
$______________ (Print the Fee Charged). There is no charge for<br />
<strong>medical</strong> <strong>record</strong>s if copies are sent <strong>to</strong> facilities or providers for ongoing<br />
<strong>medical</strong> care or follow up treatment.<br />
___________________________________________________________________________________<br />
Signature <strong>of</strong> Patient<br />
Date<br />
____________________________________________________________________________________<br />
Signature <strong>of</strong> Parent/Legal Guardian/Authorized Person<br />
Date<br />
____________________________________________________________________________________<br />
Records Received By Date Relationship <strong>to</strong> Patient<br />
FOR OFFICE USE ONLY<br />
DATE REQUEST FILLED: ________________________________ BY: _________________________________________<br />
IDENTIFICATION PRESENTED: __________________________ FEE COLLECTED: $_________________<br />
REQUEST FOR RECORDS DENIED LETTER SENT TO PATIENT BY: _________________________<br />
SECOND-LEVEL REVIEW APPROVED<br />
Page 2 <strong>of</strong> 2<br />
PP933B/Autho for Release form US/4/08/bc