Form #17 - AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION : Torrance Memorial Medical Center

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION - Form #17

I WOULD LIKE TO PICK UP ________
PLEASE MAIL ________

Completion of this document authorizes the 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.

I hereby authorize Torrance Memorial Medical Center to use or disclose my protected health information as follows:

PATIENT IDENTIFICATION:

Patient Name:
Social Security Number:	Date of Birth:	** Phone number where we may contact you: ( )
**Note: O.K. to leave message with detailed information Leave message with call back number only

RELEASE TO:

Persons/Organizations/Patient: Name:
Address:
City, State, Zip:	Phone no: ( )

I REQUEST COPIES OF MY MEDICAL RECORD:

For my physician (no charge for copies)	For my attorney (there will be a charge)
As the Patient (Please see note)**	Other (there may be a charge)
**Note: The law makes access conditional upon payment of allowable charges

TYPE OF INFORMATION TO BE RELEASED:

This authorization applies to the following information (select only one of the following):

All health information pertaining to any medical history, mental or physical condition
and treatment received. [Optional] Except:

  Only the following records or types of health information (including any dates):
        1.
        2.

EXPIRATION AND SIGNATURE:

This authorization expires on [insert date]:	I would like a copy of this authorization
Signature: (patient, representative, spouse)	Date:	Time:
If signed by someone other than the patient, state your legal relationship to the patient:

NOTICE OF RIGHTS AND OTHER INFORMATION

I may refuse to sign this Authorization. If you do, we will not be able to release your medical records to you or the requestor.
I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered or mailed to the:    Health Information Management Department
   Torrance Memorial Medical Center
   3330 Lomita Blvd.
   Torrance, CA. 90505

My revocation will be effective upon receipt, but will not be effective to the extent that the Requestor or others have acted in reliance upon this Authorization.
I have a right to receive a copy of this authorization.
Neither treatment, payment, enrollment nor eligibility for benefits will be conditioned on my providing or refusing to provide this authorization.
Information disclosed pursuant to this authorization could be re-disclosed by the recipient and might no longer be protected by federal confidentiality law (HIPAA). However, California law prohibits the person receiving my health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.
I may inspect or obtain a copy of the protected health information that I am being asked to release.

REVOCATION OF REQUEST:

I would like to revoke this Authorization for Use or Disclosure of Protected Health Information request.
Signature: (patient, representative, spouse)	Date:	Time:
If signed by someone other than the patient, state your legal relationship to the patient:
Torrance Memorial Medical Center Representative Signature:	Date:	Time:

OFFICE USE ONLY:

Records received by:	Date:	Time:
Mailed out:	Date:	Time:
HIM Personnel Signature:	Date:	Time: