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Get CA UCSF 756-020Z 2015-2024

DATE ID VERIFICATION TYPE PATIENT NAME BIRTHDATE ID VERIFIED BY AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION I authorize The purpose of this release is Name of person or facility which has information - example UCSF/Mt. Treatment payment enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases 1 to conduct research-related treatment 2 to obtain information in connection with eligibility or enrollment in a health plan 3 to determine an entity s obligation to pay a claim or 4 to create health information to provide to a third party. writing signed by you or your patient representative and delivered to Parnassus Ave. Room A68 San Francisco CA 94143-0308. The revocation will take effect when UCSF receives it except to the extent UCSF or others have already relied on it. If no date is indicated the Authorization will expire 12 months after the date of my signing this form. Print Name Date Signature Patient Parent Guardian Time Requested format Paper CD Relationship to Patient Parent Guardian Conservator Patient Representative NOTICE UCSF and many other organizations and individuals such as physicians hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential it may no longer be protected by state or federal YOUR RIGHTS This Authorization to release health information is voluntary. Zion for check one or more to release health information to Continuity of care or discharge planning Billing and payment of bill information full address patient representative Street address City State Zip Code Please specify the health information you authorize to be released Type s of health information Date s of treatment 756-020Z Rev* 02/12 WorkflowOne MEDICAL RECORD COPY The following information will not be released unless you specifically authorize it by marking the relevant box es below Information pertaining to drug and alcohol abuse diagnosis or treatment 42 C. F*R* 2. 34 and 2. 35. Institutions Code 5328 et seq. Release of HIV/AIDS test results Health and Safety Code 120980 g. Release of genetic testing information Health and Safety Code 124980 j. EXPIRATION OF AUTHORIZATION Unless otherwise revoked this Authorization expires insert applicable date or event. Treatment payment enrollment or eligibility for benefits may not be conditioned on signing this Authorization except in the following cases 1 to conduct research-related treatment 2 to obtain information in connection with eligibility or enrollment in a health plan 3 to determine an entity s obligation to pay a claim or 4 to create health information to provide to a third party. writing signed by you or your patient representative and delivered to Parnassus Ave. Room A68 San Francisco CA 94143-0308. The revocation will take effect when UCSF receives it except to the extent UCSF or others have already relied on it.

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