Medical Records Release
AUTHORIZATION FOR USE AND DISCLOSURE OF MEDICAL INFORMATION - Please complete the form below if you would like Los Gatos Doc to upload your medical information and records to a USB Flash drive.
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This authorization allows the healthcare provider named below to release confidential medical information and records. Los Gatos Doc will upload medical records to a USB Flash drive that you may pick up at the Los Gatos Doc’s office.
Note: Information and records regarding treatment of minors, HIV, psychiatric/mental health conditions, or alcohol/substance abuse have special rules that require specific authorization.
I hereby authorize: Dr. Arun Villivalam, MD of Los Gatos Doc, Inc. to release information (patient name and date of birth noted below) regarding my medical history, illness or injury, consultation, prescriptions, treatment, diagnosis or prognosis, including x-rays, correspondence and/or medical records including those from my other health care providers that the above named health care provider may hold, by electronic methods.
First Name *
Last Name *
Date of birth *
MM
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DD
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YYYY
The authorization is: *
Required
I also consent to the specific release of the following records: *
Required
Expiration: This authorization shall become effective immediately and shall remain in effect for one (1) year from the date signed.
FEES:
Please note that there are processing fees associated with a release of medical records. Refer to the Medical Records Release Policy for more information on this.
RESTRICTIONS:
Permission for further use or disclosure of this medical information is not granted unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
A photocopy of facsimile of this authorization shall be considered as effective and valid as the original.
I have been advised of my right to receive a copy of this authorization.
If applicable, please specify the full name of the individual or entity with whom you would like Los Gatos Doc to share your medical records below:
Signature of patient or legal / personal representative *
Email address *
Relationship if other than patient
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