This form is used to authorize the company to obtain results of an employee's drug or alcohol tests or other medical tests.
Long Beach California Authorization for Disclosure of Medical Information
Category:
State:
California
City:
Long Beach
Control #:
CA-JM-0020
Format:
Word
Instant download
Description
How to fill out California Authorization For Disclosure Of Medical Information?
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FAQ
Contact Us Contact Us. Hospital Operator: (323) 409-1000. Monday ? Sunday. 24 hours a day. Medical Records/Release of Information: (323) 409-6118. Monday ? Friday. A.M. to P.M. Pharmacy: (323) 409-6763. Monday ? Sunday. A.M. to P.M.
I was treated in your office at your facility between fill in dates. I request copies of the following or all health records related to my treatment. Identify records requested, e.g. medical history form you provided; physician and nurses' notes; test results, consultations with specialists; referrals.
The core elements of a valid authorization include: A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.
In general, under the provisions of the FOIA and Privacy Act, access to information about private individuals cannot be given to unauthorized third parties without the individual's written consent.
An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.
The patient's legal name, date of birth, gender, Social Security number, address, telephone number, guarantor, subscriber, or next-of-kin are key identifying elements that assist in establishing the proper individual.
An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the
The patient name, date of birth, name of releasing institution, name of receiving institution, condition for which the patient was treated, purpose of the disclosure, signed and dated by the patient or legal guardian, expiration date, statement that the authorization can be revoked.
Generally, an authorization provides the authority for a doctor's release of PHI for specified purposes, which are generally other than treatment, payment, or healthcare operations, or, to disclose protected health information to a third party specified by the individual.
For current and former patients seeking to verify medical records, including appointment history, a completed authorization for disclosure of health information form must be signed (e-signatures are not accepted) and submitted with a copy of a government-issued ID to the Health Information Management Office by fax at (
