"Authorization to Release Hospital Record Information" - California

This California-specific "Authorization To Release Hospital Record Information" is a document released by the California Department of Health Care Services.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Authorization to Release Hospital Record Information" - California

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AUTHORIZATION TO RELEASE HOSPITAL RECORD INFORMATION
Authorization with an original signature* of an officer of the hospital is required to
release hospital confidential data to persons not associated with the hospital.
Please release hospital confidential data to:
NAME:
ADDRESS:
PHONE:
SIGNATURE:
Officer authorizing release of hospital confidential data:
NAME:
TITLE:
HOSPITAL:
ADDRESS:
PHONE:
SIGNATURE:
*A FAXed document does not satisfy the criteria for an original signature.
Please complete, sign, and mail to:
Department of Health Care Services
Disproportionate Share Hospital Unit
1501 Capitol Avenue, MS 4506
P.O. Box 997419
Sacramento, CA 95899-7419
AUTHORIZATION TO RELEASE HOSPITAL RECORD INFORMATION
Authorization with an original signature* of an officer of the hospital is required to
release hospital confidential data to persons not associated with the hospital.
Please release hospital confidential data to:
NAME:
ADDRESS:
PHONE:
SIGNATURE:
Officer authorizing release of hospital confidential data:
NAME:
TITLE:
HOSPITAL:
ADDRESS:
PHONE:
SIGNATURE:
*A FAXed document does not satisfy the criteria for an original signature.
Please complete, sign, and mail to:
Department of Health Care Services
Disproportionate Share Hospital Unit
1501 Capitol Avenue, MS 4506
P.O. Box 997419
Sacramento, CA 95899-7419
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