Medical Records Form

Authorization for Use or Disclosure of Health Information
Completion of this document authorizes the disclosure and/or use of health information about you. Failure to provide all information may invalidate this Authorization.
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
I hereby authorize:
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
To Release to:
Dr. Shilpa Sayana
11724 Ventura Blvd., Suite A // Studio City, CA 91604
(818) 331-4386
The following information: [Select One]
- All health information pertaining to my medical history, physical condition, treatment received
- Only the following records or types of health information (including any dates):
Select Health Records to Share (Include Dates)
Purpose of requested use or disclosure (Select One)
- Patient Request
- Other
If Other Please Specify Details
Expiration: This Authorization expires one (1) year from the date signed.
My Rights
- I may refuse to sign this Authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits.
- I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of.
- I may revoke this authorization at any time, but I must do so in writing and submit it to my healthcare center.
- My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization.
- I have a right to receive a copy of this authorization.
- I understand information disclosure pursuant to this authorization could be re•disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law (HIPAA). If the disclosure is to Sayana Medical & Wellness Center, the Center will only release as allowed by law.
Signature
Signed By (Select One)*
- Patient
- Legal Representative
If signed by someone other than the patient, state your legal relationship to the patient:

Medical Records Form

Authorization for Use or Disclosure of Health Information

I hereby authorize:

Expiration: This Authorization expires one (1) year from the date signed.

Sayana Medical & Wellness Center

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