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: 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________________