AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS - JIT 2363 Side 2 of 2 Rev 04/23/24

Oct 13, 2026

Upload by sagouaw

Authorization form for releasing copies of medical records from Hoag Memorial Hospital Presbyterian or its affiliates to a designated person or organization. Collects patient demographics, recipient contact details, delivery method (mail, pickup, paper or electronic options such as secured email or patient portal), and specific record types and service dates. Includes requested information categories, purpose of disclosure, and expiration (default one year). Provides patient/legal representative signature fields and a notice of rights, including refusal and written revocation procedures.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Patient and Recipient Information

Record Type, Dates of Service, and Delivery Options

Specific Information and Purpose of Disclosure

Signature, Expiration, and Rights Notice

Patient Name: Date ofBirth: I hereby authorize Hoag Memorial Hospital Presbyterian, or its affiliates and affiliated providers to disclose the information listed belowto: (List the person/organization authorized to receive this information.) Name/Organization: Address: City: State: Zip: Phone: | Please select the type of formatthe records should be in: Paper CD USB
Please select howyou would like to receive the records: Mail to the address above
Patient will pick up
I authorize to pick up my medical record copies. | | --- | | Or you may receive the records electronically (please select):
Secured Email:
MyChart (patient portal)
Secure Medical Image Exchange (Radiology/Cardiology images only): Email: | This authorization applies to the following: Date(s) of Service: ED/Urgent Care Records History & Physical Consults Operative Report Discharge Summary MD Notes MD Orders Nurse’s Notes EKG, EMG, EEG Radiology Reports Anesthesia Records Lab/Pathology Reports Immunizations Radiology Images, Exam: Outpatient/Clinic Record – Clinic/Provider Name: Other: I specifically authorize release of the following information (check as appropriate) : Substance Use Disorder treatment information HIV Test Results Mental Health Treatment Information A separate authorization is required to authorize the disclosure or use of psychotherapy notes. Purpose for use/disclosure: Patient Request Further Medical Care Insurance OR Other: Expiration: This authorization will expire in 1 year from date of signature unless another date or event is specified: Patient/Legal Representative Signature: Date: Time: AM/PM If signed by other than patient, indicate legal relationship to patient: Print Name (Legal Representative): AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS JIT 2363 Side 2 of 2 Rev 04/23/24 *7715* [7715] Original – Chart Copy – Patient MR \# AUTHORIZATION TO RELEASE COPIES OF MEDICAL RECORDS Completion of this document authorizes the disclosure and/or use of individually identifiable health information, as set forth below, consistent with California and Federal law concerning the privacy of such information. Failure to provide all information requested may invalidate this authorization: Notice of Rights and Other Information: 􀁸 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 revoke this authorization at any time. My revocation must be in writing, signed by me or on my behalf, and delivered to Hoag Hospital, Health Information Department, One Hoag Drive, Newport Beach, CA 92658. My revocation will be effective upon receipt, but will not be effective to the extent that the requestor or others have acted in reliance on this authorization. 􀁸 I have a right to receive a copy of this authorization. 􀁸 Information disclosed pursuant to this authorization could be re-disclosed by the recipient and might no longer be protected by federal confidentiality law (HIPAA) . However, California law prohibits the person receiving patient health information from making further disclosure of it unless another authorization for such disclosure is obtained from the patient or authorized representative or unless such disclosure is specifically required or permitted by law. 􀁸 I may inspect or obtain a copy of the health information that I am being asked to allow the disclosure of. Complete request information on reverse side... Side 1 of 2

FAQs

Who can receive the medical records under this authorization?

The form authorizes Hoag Memorial Hospital Presbyterian (or its affiliates and affiliated providers) to disclose the listed information to the designated person or organization listed on the form.

How can the patient choose to receive the records?

The patient can select delivery format (Paper, CD, USB) and delivery method (mail to the address above or pick up). Electronic delivery options include secured email, MyChart (patient portal), or secure medical image exchange for radiology/cardiology images.

When does this authorization expire and how can it be revoked?

It expires in 1 year from the date of signature unless another date or event is specified. The patient may revoke it at any time by written revocation delivered to Hoag Hospital, Health Information Department, and revocation takes effect upon receipt, with limited exceptions for actions already relied upon.

Oct 13, 2026

Upload by sagouaw