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Print in ink u Failure to provide all information may invalidate this authorization - medical-center

Print in ink u Failure to provide all information may invalidate this authorization - medical-center 2026

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The document is an authorization form for the disclosure of protected health information from Loma Linda University Medical Center and its affiliated facilities. It outlines the necessary details for releasing medical records, including patient identification, types of information to be disclosed, purpose of disclosure, and patient rights regarding revocation and inspection of their health information. The form emphasizes that signing is voluntary and provides information on potential fees for accessing records.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the 'From Whom' section, specifying the clinic or physician from which you are requesting records.
In the 'To Whom/Inspect' section, choose whether to send records to an individual or agency, and provide their name and address.
Specify the information to be released by indicating where services were rendered and selecting relevant treatment dates and types of documents needed.
Indicate the purpose for disclosure by selecting one of the options provided, such as 'Continued Care' or 'Personal Use'.
Complete the patient identification section with your name, last four digits of your SSN, birth date, and phone number.
Sign and date the form. If signed by a legal representative, include their relationship to the patient.

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