Completion of this document authorizes the use and disclosure of health
information about you. Failure to provide all information requested may
invalidate this authorization.
Patient Identifying Information
Use and Disclosure of Health Information
The following individual or organization is authorized to receive/review
the above named patient’s health records. I understand there may
be circumstances that would allow the Hospital to receive a fee in exchange
for disclosing the information requested on this Authorization.
I hereby authorize Pomona Valley Hospital Medical Center
to release to:
the following information, including any dates, (choose one):
I understand that the information in my health record may include information
related to sexually transmitted disease(s) (STDs), AIDS or HIV. It may
also include information about behavioral or mental health services and
treatment for alcohol and drug abuse.
I specifically authorize release of the following information
(Initial as appropriate)
Requested use or disclosure:
- I may refuse to sign this authorization. My refusal will not affect my
ability to obtain treatment or payment or eligibility for benefits.
- I may inspect or obtain a copy of the health information that I am being
asked to allow the use or disclosure of.
- I may revoke this authorization at any time, but I must do so in writing
and signed by me or on behalf of me and submitted to: Pomona Valley Hospital
Medical Center ATTN: Health Information Management Department, 1798 N.
Garey Ave. Pomona CA 91767.
- My revocation will take effect upon receipt, except to the extent that
the Hospital or others have acted in reliance upon this authorization.
For further information, please see Hospital’s Notice of Privacy
- I have a right to receive a copy of this authorization. I acknowledge that
this Authorization was filled out completely when I signed the Authorization.
- Information disclosed pursuant to this authorization could be redisclosed
by the recipient. Such redisclosure is in some cases permitted by California
law and may 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.
By printing your name and submitting this form, you are indicating that
all of the above inforamtion is true and accurate.