I hereby authorize __________________________________, M.D., to furnish medical information concerning _______________________________________ (patient’s name) to Dr. ___________________________________________________________________________
______________________________________ (name and address of person to receive records).
Any and all information may be released, including, but not limited to, mental health records protected by the Lanterman-Patris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any, except as specifically provided below:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The information may be used only for the following purposes:*
______________________________________________________________________________
This authorization is effective now and will remain in effect until
________________________________ (date).
I understand that I have the right to receive a copy of this authorization.
Signed: _____________________________ Date: _______________________
If not signed by the patient, please indicate relationship:
[ ] parent or guardian of minor patient (to the extent minor could not have consented to the care)
[ ] guardian or conservator of an incompetent patient
[ ] beneficiary or personal representative of deceased patient **
[ ] spouse or person financially responsible (where information solely for purpose of processing application for dependent health care coverage)
* Signed: ___________________________ Dated:
_________________________
Physician
Note To be valid, this authorization must be handwritten by the person who signs it or in typeface no smaller than 8-point type (this is 8-point type). It must be clearly separate from other language on the page and executed by a signature which serves no purpose other than to execute the authorization.
For the release of records (1) protected by the Lanterman-Petris-Short Act (LPS) or (2) containing HIV test results, a separate authorization is required for each separate disclosure. Further, the LPS Act often requires that both the patient’s treating physician and the patient, or representative, sign the authorization form before information can be released.
** It is unclear whether the beneficiary or personal representative of a deceased patient can obtain and disclose certain specific records, such as mental health records covered by the Lanterman-Petris-Short Act and/or HIV test results.