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Medical Records Request Use Or Disclosure Authorization

  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

  • Pursuant to the health Insurence Portability and Accountability Act(HIPAA) I/We, Hereby Authorize the following Provider(s)
  • *** It’s important that we have your doctor’s fax #, please call your doctor’s office for the fax #.
  • To disclose the following protected health information to
  • Coastal Fertility Medical Center
  • 15500 Sand Canyon Ave., Suite 100
  • Irvine, California 92618 Tel: 949-726-0620 Fax: 949-726-0653
  • Attention: Lupe Castaneda
  • Mcdical History, including specific progrcss notcs regarding any problcms that would impact my treatments progress or outcome.
  • Results of relevant diagnostic or laboratory tests.
  • This protected health information is being used by the practice for the purpose of preparation treatment at the Coastal Fertility Medical Center. This authorization shall be in force and efect until………….(Date).
  • I understand that, as set forth in the Practice’ s Privacy Notice, I have the right to revoke this authorization, in writing, at any time by sending written notification to: Coastal Fertility Medical Center, 15500 Sand Canyon, Suite 100, Irvine, California 92618, Attn: Privacy Officer
  • I understand that a revocation is not effective to the extent that the Practice has relied on the use or disclosure of the protected health information.
  • I understand that information used or disclosed pursuant to th is authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
  • I understand that the Practice will not condition my treatment on whether I prov ide authorization for the requested use or disclosure.
  • I understand that I have the right to:
    • Inspect or copy my protected health information to be used or disclosed as pennitted under federal law (or state law to the extent the state law provides greater access rights.)
    • Refuse to sign this authorization.

  • Date Format: MM slash DD slash YYYY

  • Date Format: MM slash DD slash YYYY

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