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 ______________________________________

 

PATIENTíS NAME:_______________________________________________________________≠_

 

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

 

ADDRESS:_________________________________________________________________________

 

I HEREBY AUTHORIZE:DOCTOR OR CLINIC TO RELEASE INFORMATION:

 

___________________________________________________________________________________

 

ADDRESS:________________________________________________________________________

 

 

TO RELEASE MY MEDICAL RECORDS TO: (circle one) ††††††††† DR. JAYA VIRMANI

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† DR. SOA TSUNG

At: ††††† 1900 El Camino Real

††††††††††††††††††††††† SUITE #119††††††††††††††† ††††††††††††††††††††††††††††††††††† Tel:††††† (650)327-3000

MENLO PARK, CA 94027††††††††††††††††††††††††††† Fax: ††† (650)327-3180

††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††

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:†††††††

 

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 until _______________________.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________________