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Patient Release Authorization Form

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Personal Information
  • * Indicates Required Field
  • Patient Identifying Information
  • Please enter patient's first name.
  • Please enter patient's last name.
  • Please enter patient's date of birth.
  • Please enter patient's last four of SSN.
  • 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:

  • Please enter the name of the person or organization.
  • This isn't a valid phone number.
    Please enter a phone number.
    You entered an invalid number.
  • Please enter the street address.
  • Please enter the city.
  • Please enter the state.
  • Please enter the zip code.
  • 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.

  • Please enter your initials.
  • I specifically authorize release of the following information

    Initial as appropriate

  • Purpose
  • Requested use or disclosure
  • Your rights
    • 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 Practices.
    • 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.
  • Please enter your signature.
  • By printing your name and submitting this form, you are indicating that all of the above inforamtion is true and accurate.