Medical records release form california. Your medical identification number or other identifier used dear. The medical board of california is the state agency that licenses medical doctors investigates complaints disciplines those who violate the law conducts physician evaluations and facilitates rehabilitation where appropriate. Join us for the pacific veterinary conference in sunny long beach ca. Registration open for the pacific veterinary conference june 21 24 2019.
Download and print the authorization for release of health information form below. The health information management department at saint agnes uses a state of the art electronic medical record system. This creates a more secure environment for health information however still provides immediate access for physicians to review the patients medical record. Authorization for release of information to a third party a non ucla provider insurance company attorney etc.
Patients can also submit requests by mail or in person see details below. Your name your address date name of care provider or facility address re. The medical records department maintains medical patient data in a secure manner allowing release only to recognized entities with legal right to review the contents. The sample medical records release form below details an agreement among the patient thomas e beckman the person who will releasing the information jeane r gano and the person who will be receiving the information mark t landis.
To comply with applicable laws requests for medical records must be made in writing. If a patient requests medical records from our office and in addition records from previous offices in which she was seen that were transferred to us are we obligated to provide records from all the previous offices or can we refer the patient to the original office in which she was seen.