St John's Regional Medical CenterOxnard, CADignity Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields. Fill in your name, date of birth, and any other names you have used. Ensure accuracy as this information is crucial for identification.
3. Next, indicate the medical facility you authorize to disclose your health information by checking the appropriate box for St. John’s Regional Medical Center or St. John’s Hospital Camarillo.
4. Specify who will receive your health information by filling in their name and address in the provided fields.
5. Select the types of records you wish to disclose by checking the relevant boxes. You can choose specific records like laboratory tests or all records related to your treatment.
6. Indicate how you would like to access your health information by selecting either paper or electronic format.
7. Finally, sign and date the form at the bottom, ensuring that all required fields are completed before submission.

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