Authorization to Release Healthcare Information

Patient's Name*

First Name

Initial

Last Name

Patient's Birth Date*

Social Security Number

I request and authorize TOWER IMAGING VALENCIA to release healthcare information of the patient named above to:

Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:

All healthcare information Healthcare information relating to the following treatment, condition, or dates: Other

MY RIGHTS

I understand I do not have to sign this authorization in order to get healthcare benefits (treatment, payment, or enrollment). However, I do have to sign an authorization form:

• To take part in research study or

• To receive healthcare when the purpose is to create healthcare information for a third party

I may revoke this authorization in writing. If I did, it would not affect any actions already taken by Tower Imaging Valencia Radiologists based on this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:

• Fill out a revocation form. A form is available at Tower Imaging Valencia.

• Write a letter to Tower Imaging Valencia, attn: Jeanne Garcia.

Once healthcare information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

Patient / Responsible Party Signature*

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Use your mouse or finger to draw your signature above