Medical Release Form - Monterrey County Sheriff
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1MEDICAL
MONTEREY COUNTY, CALIFORNIA
RELEASE
SHERIFF’S OFFICE
K e e p i n g t h e p e a c e s i n c e 1 8 5 0
■
■
1414 Natividad Road, Salinas CA 93906
(831) 755-3700
AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION
EXPLANATION
Your authorization for the use and/or disclosure of individually identifiable medical/health information is being requested, in order to
comply with the provisions of California and Federal law, including both the Confidentiality of Medical Information Act of 1981, Civil
Code Section 56, et.seq., and the federal Health Insurance Portability and Accountability Act (“HIPAA”).
AUTHORIZATION
I hereby authorize ___________________________________________________________________________
Facility name(s) – Printed
to furnish to the MONTEREY COUNTY SHERIFF’S OFFICE copies of medical records and information pertaining
to: the medical history; mental and/or physical condition(s); service(s) rendered; and/or treatment of:
_____________________________________
____________________
Name of Patient
Date of Birth
This authorization is limited to the following medical records and type(s) of information: Records or information
pertaining to my medical history; injuries; and my health care
from ____________________ to ____________________
Enter inclusive dates
I agree that any and all persons competent to do so may testify as to such records and the health or other
information contained in them in any relevant legal or administrative proceeding.
USES
The requester may use the medical records and type of information authorized only for the following purpose(s):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
DURATION
This Authorization shall become effective immediately and shall remain in effect until _______________________
Enter Date – not to exceed one year
unless sooner revoked by me in writing. My revocation will be effective upon receipt, but will not be effective to the
extent that the Sheriff’s Office or others have acted in reliance upon this Authorization.
_____________________________________
____________________
Patient / Legal Representative
Date
If signed by Legal Representative, state your relationship to the patient: ____________________
_____________________________________
____________________
Witnessed
Date
Form # SO1025.01 Revised 04.01.2015
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