Authorization To Use Or Disclose Protected Health Information
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1
2CANYON RIDGE HOSPITAL
AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
REQUESTOR INFORMATION
Name:
Facility
:
(opt.)
Address:
Telephone:
City, State, Zip:
Email:
PATIENT INFORMATION
First Name:
Date of Birth:
Last Name:
SS #:
DISCLOSURE STATEMENT
I hereby authorize Canyon Ridge Hospital or ______________________________ (other), to release
protected health information to the following person or entity:
Facility/Person:
Contact Name:
Address:
Telephone:
City, State, Zip:
HEALTH INFORMATION TO BE RELEASED
Discharge Summary
History & Physical Exams
Psychiatric Evaluation
Laboratory Reports
Other:
DATES OF SERVICE
Most Recent Visit
Date(s):
PURPOSE
Continuing or Follow-up Care
Other:
DELIVERY METHOD
U.S. Mail
Send to Doctor:
Other
Doctor Tel:
Doctor Fax:
Note: Important information and signatures required on reverse side of form.
Unsigned requests cannot be processed.
Please see reverse side of this page.
5353 G. Street, Chino, CA 91710 | Tel: (909) 590-3700 x2060 | Fax: (909) 590-4038
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Parent category: Business