Please fill out the form below for release of records to another office and mail to us. Every section needs to be completed including initials and Yes/No on the mental health/HIV section. We cannot proceed without all sections filled out correctly.

PLEASE NOTE: If you check “NO” on the mental health/drug/alcohol/HIV section it will take several weeks to take the time to search your record to redact any mention of these items.

The fees for copying are based on number of pages of records. If the cost to copy records is more than $125, we will notify you before copying. Pre-payment is required so please fill out the credit card authorization information below or call us to give a credit card number.

Based on our experience, some clinics/offices lose records that are sent to them. If you choose to have records mailed to a clinic/office and they lose them, the same fee will apply to mail a second set of records.

Please initial one option:

____Mail to me _____Mail to physician on release form ___I will pick up records

In what format would you like the records? (CD preferred by most places):

______CD (compact disc) ______ Paper

Credit card information:
Name on card: _______________________________

Patient name: _______________________________ DOB: ________________

Card number (VISA, MC only): _________________________________________

Exp date: __________________

CSC # (3 digit on back of card): _____________________

Billing address: _______________________________________________________

City: ____________________________ Zip: _______________________

Thank you and have a nice day. Tsung & Virmani Medical Group, Inc.

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

This authorization for Tsung & Virmani Medical Group, Inc. for use or disclosure of my health information is being requested of you to comply with state and federal law. The recipient may use my health information only for the following purpose: medical care □ or ______________________________________

PATIENT’S NAME: ________________________________________________________________

BIRTH DATE (month/day/year) ____/____/______ TELEPHONE NUMBER_______________

ADDRESS:_________________________________________________________________________

I HEREBY AUTHORIZE:

(circle one) DR. JAYA VIRMANI 1900 EL CAMINO REAL

DR. SOA TSUNG SUITE #119

Tel: (650)327-3000 MENLO PARK, CA 94027

Fax: (650)327-3180

TO RELEASE MY MEDICAL RECORDS TO:

NAME:___________________________________________________________________________

ADDRESS: ________________________________________________________________________

PHONE: ____________________________________________

Please send a copy of my medical records covering the last _________ years.

Specific information requested:

	PLEASE CHECK BOX OR WRITE COMMENT:
ALL RECORDS
LAB
IMAGING REPORTS
VACCINES
OTHER

Specific authorization is required to release information regarding the following (must be filled out)

	Yes	No	Initials
HIV information
Drug/alcohol information
Mental Health information

Restrictions: California law prohibits the recipient from making further disclosure of you health information unless the recipient obtains another authorization from you or unless the disclosure is required or permitted by law. This protection does not extend to recipient outside the State of California. This authorization shall be valid for 1 year or ______________. Please indicate date after which no information can be released. If no date is given, authorization is valid for 90 days only. I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment. I may revoke this authorization at any time, in writing. The revocation must be signed by me or on my behalf and sent to the address on the top of this form. The revocation is effective upon receipt but will have no impact on uses or disclosures made while the authorization was valid. I have a right to a copy of this authorization. Copy requested □yes □no Copy received initials________

PATIENT or REPRESENTATIVE SIGNATURE _________________________________________

RELATIONSHIP TO PATIENT ______________________________ DATE__________________