Community Memorial Health Systems (Authorization for Use or Disclosure)

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

Authorization for Use or Disclosure of Health Information Autorizacion para el Uso o Divulgacion de la Informacion de Salud

*Patient's Name:

*Birth Date:

*Address:

*City:

*State:

*Zip Code:

*Phone Number:

MR#:

Bill#:

Completion of this document authorizes the disclosure and/ or use of individually identifiable health information, as set forth below, consistent with California and Federal law concerning the privacy of such information.

Failure to provide all information requested may invalidate this authorization.

NOTICE OF RIGHTS AND OTHER INFORMATION NOTIFICACIÓN DE DERECHOS Y OTRA INFORMACIÓN

1.

I understand that this authorization is voluntary.

2.

I may refuse to sign this authorization.

3.

My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance upon this authorization. I understand the Notice of Privacy Practices provides instruction should I choose to revoke my authorization.

4.

Neither treatment, payment, enrollment nor eligibility for benefits will be conditioned on my providing or refusing to provide this authorization.

5.

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 health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.

6.

I may inspect or obtain a copy of the health information that I am being asked to use or disclose.

7.

If this box is checked, the requestor will receive compensation for the use or disclosure of my information.

8.

I may revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to: Community Memorial Hospital, Health Information Department, 147 N. Brent Street, Ventura, CA 93003.9

9.

I understand that I have the right to choose how I am to receive my health information.

a. Please choose a mode of delivery (choose one option):

1. Mail (address listed below)

2. Secure email to:

3. Fax request to:

4. In-person (by appointment only)

b. Please choose a format (choose one option):

1. Paper

2. CD or flash drive (circle one)

3. Electronic file in “pdf” format

c. Please be advised that with utilizing fax or secure e-mail, there is some level of risk that your requested health information could be read or otherwise accessed by a third party while in transit.

I understand I have the right to receive a copy of this authorization. (Civ. Code § 56.12)

*I hereby authorize:

Community Memorial Hospital

Ojai Valley Community Hospital

Centers for Family Health/Clinics

Other entity:

*to release to:

*Address:

*City:

*State:

*Zip Code:

Fax: