[Date]
CONFIDENTIAL
Patient’s Name
Address
City, State Zip
Re: Release of Medical Information
Dear Patient:
I am in receipt of both your general authorization for release of your medical records (insert entity name) and of your request that certain information in the record not be disclosed. I understand the need for confidentiality concerning the medical information in your file. The principal California statute governing confidentiality of medical information is the Confidentiality of Medical Information Act. Civil Code §56 et seq. This act prohibits disclosure of medical information absent an authorization signed by the patient or the patient’s legal representative. Except as authorized by this statute and other relevant laws, I will not release information regarding your medical condition and treatment without having first obtained your prior written authorization.
However, you should be aware that if you refuse to permit disclosure of certain information to certain entities, this may make it impossible for me to respond to requests from such entities for your health care records. For example, if you apply for life or health insurance coverage, such insurers will, no doubt, ask you to authorize release of your health care records as part of the application process. If you then notify me that, despite the general authorization which you signed, you do not want selected information disclosed, I will not be able to assist you in your effort to obtain insurance coverage. I cannot disclose only a portion of your medical information without notifying the insurer that a portion of the file has been withheld at the patient’s request.
If the information you do not wish disclosed is covered by a special statutory confidentiality protection, the situation will be different. If that is the case, I may disclose your general medical information (without the specially protected information) and provide the entity with a boilerplate notification as part of the disclosure, which states:
“This disclosure does not contain information, if any exists, that is protected by special state and/or federal confidentiality requirements. Such information, if it exists, can only be released pursuant to special patient authorization.”
If you believe that the information you wish to withhold is covered by such a special protection, please notify me of that protection immediately and, if appropriate, I will disclose the information other than that which is specially protected, along with the boilerplate notification listed above. You should be aware, however, that upon receiving such a notice, the insurer or other entity will almost certainly ask you to sign a specific authorization for disclosure of the otherwise confidential information.
Please note also that the law allows physicians to share medical information for both treatment and billing purposes, even absent a patient’s written consent. Moreover, the law requires physicians to share medical information under some circumstances, such as pursuant to a valid court order.