AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

 

 

I Authorize:                 Health Information Department

                                    UCD Women’s Center For Health

                                    1370 Prairie City Road

                                    Folsom, CA 95630

 

From:               Name: _________________________________________

 

                        DOB:  _________________________________________

 

I have previously received care at the Women’s Center for Health, Folsom.  I authorize UCDHS at my own request to release my medical records for the purpose of continuity of my health care.   Please promptly provide to my doctor at the address below the information as listed below.  This authorization is completely voluntary.  This authorization may be revoked at any time (supplied in writing to addressee).  I have kept a copy of this authorization.  Unless otherwise revoked, this authorization will expire one year after the date of signature.

 

·                     a Clinical Summary:  including information that may include (initial lines:

_______    HIV test results (Health & Safety Code 120980(g)).

_______    Genetic testing information (Health & Safety Code 124980(j))

·                     a copy of my most recent pap smear report

·                     a copy of my most recent mammogram report

·                     a copy of my most recent pelvic ultrasound report (if available)

·                     a copy of my most recent complete visit with my gynecologist

·                     a copy of an episode review for each pregnancy available in EMR

 

 

 

Please release this health information by mailing it to:

            Dr. Ruth Haskins

            1611 Creekside Drive Suite 103

            Folsom, CA 95630

 

 

Print Name:   _______________________________________________

 

Signed:            _______________________________________________

 

Date:               ________________________        Time:  ______________