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Click ‘Get Form’ to open the medical release of information in the editor.
Begin by filling out Section A. Enter the patient's name, birth date, provider's name, and recipient's name. Optionally, include the social security number.
Complete the provider's address fields, including street address, city, state, and zip code.
Specify the expiration date or event for this authorization. Remember that it will automatically expire 180 days after signing unless otherwise noted.
Indicate the purpose of disclosure and describe the information you wish to be used or disclosed. If applicable, check 'Yes' for psychotherapy notes; otherwise, select relevant items from the list provided.
Acknowledge consent regarding sensitive information by initialing where indicated. If not applicable, check the corresponding box.
Review your understanding of the terms outlined in Section A before proceeding to Section C for signatures.
In Section C, sign and date the form. If applicable, print your name and relationship to the patient.
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A covered entity must disclose protected health information in only two situations: (a) to individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information; and (b) to HHS when it is undertaking a compliance investigation or
What is the federal law on release of medical information?
Under HIPAA, doctors can share patient information and records as necessary. This includes general health and medical treatment. For example, say a primary care physician refers their patient for an x-ray in the same practice. The radiologist does not need consent to review the patients records.
What is the release of information in healthcare?
A valid medical release form must be used to obtain this authorization and must include specific elements, such as what PHI will be shared, who can share it, who will receive it, the purpose, and an expiration date.
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Related links
CDCR 7385, Authorization for Release of Protected Health
Medical Services is checked when the patient wishes to have information released related to medical care. Dental Services is checked when the patient
Directions: Type or Print all requested information, with exception of signatures on Page 2. Individuals Name (Beneficiary, Recipient, Patient, Consumer, etc.).
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