Get CS Form 2034 2013

Notice of Rights Signature Expiration 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 in writing signed by me or on my behalf and delivered to Cedars-Sinai Medical Center Health Information Department 8700 Beverly Blvd. AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Failure to provide all information may invalidate this authorization Patient Name Date of Birth Address City Last Name K Paper K Electronic K Inspect or Review Medical Record First Name Phone State Zip I authorize Cedars-Sinai to Release / Request Medical Records For the following Continuing Care Purpose Release To K Request From K Person / Organization City / State / Zip Legal Personal Use Based on California Evidence Code State / Federal Laws require specific authorization to release the following types of information Mental Health HIV test results Alcohol / Drug Abuse A separate authorization is required for psychotherapy notes. Insurance Other Fax Treatment Dates Discharge Summary Emergency Record Operative Report Billing Record Laboratory Report EKG Pathology Report Radiology Report Consultation Report Xray Film / Images CD Other Please Specify Outpatient / Clinic Record - Clinic / Provider Name MRN Fees Information to Release Patient Authorization for Copies of Medical Record Health Information Management Department 8700 Beverly Blvd. Room 2901 Los Angeles CA 90048 Email GroupHIDInternetInquiries cshs. org Fax 310-423-0113 Sections 1560- 1567 Fees may be charged for medical record copies. Form No* 2034 Rev* 8/15/13 Front Delivery Instructions K Mail records directly to person or organization specified K Call Requestor when records are ready for pick up I authorize Relationship to patient K E-mail to pick up my medical record copies. I understand that 1. If I refuse to sign this authorization my refusal will not affect my ability to obtain treatment. Room 2901 Los Angeles CA 90048. If I revoke this authorization the revocation will not have any effect on any actions taken prior to receiving the revocation* I have a right to receive a copy of this authorization* Information disclosed pursuant to this authorization could be re-disclosed by the recipient and may no longer be protected by federal confidentiality law HIPAA. However California law prohibits the person receiving my disclosure is specifically required or permitted by law. If this K is checked the Requestor will receive compensation for the use or disclosure of my information* Without my written revocation this authorization will automatically expire upon satisfaction of the need for disclosure but in any event will expire 180 days from the date hereof unless otherwise specified Signature Date Legal Representative Relationship Patient or Legal Representative. Insurance Other Fax Treatment Dates Discharge Summary Emergency Record Operative Report Billing Record Laboratory Report EKG Pathology Report Radiology Report Consultation Report Xray Film / Images CD Other Please Specify Outpatient / Clinic Record - Clinic / Provider Name MRN Fees Information to Release Patient Authorization for Copies of Medical Record Health Information Management Department 8700 Beverly Blvd. Room 2901 Los Angeles CA 90048 Email GroupHIDInternetInquiries cshs. org Fax 310-423-0113 Sections 1560- 1567 Fees may be charged for medical record copies. .