Saban Community Clinic

Authorization to Release Information 

I, voluntarily authorize Saban Community Clinic to disclose my health information also known as Medical Records from the patient named below and released to the named recipient or organization of my choosing.

Please complete all sections of the form and use your legal name and information specified on your official identification card or letters

    Patient Information:

    Please provide the full name of the recipient, personal representative or organization you want your records sent to. Type “Self” if the records are to go to you:

    What is the purpose for requesting records? (please check only one box)

    Continuation of Care
    Personal Use

    Please choose what you want released from your medical record:

    Last two years of relevant medical recordsI want to specify the dates and type of records to release

    Step 1: I want records between the following dates:

    Step 2: Select the one or more types of the record you are requesting:

    All Medical Records (Includes all the options below)
    Progress Notes
    Dental (Xray Only)
    Dental Notes
    Radiology/Imaging Reports
    Billing Records
    Lab Results
    Other (please specify)

    Special Instructions:

    The following information will be excluded unless you specify by checking the box(s) below that you want to include these records in your request:
    Alcohol/Drug Abuse Treatment
    HIV/AIDS related Treatment
    Behavioral Health (excluding psychotherapy notes)

    How do you prefer to receive the records?

    My Chart
    Pick Up In Person
    Secure E-Mail
    Fax (50+ pages will be mail to provided address)

    By signing this Authorization for Release of Information you agree to the following terms:

    Health information released by this authorization (except for Alcohol and Drug Abuse) may be subject to release by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act (HIPAA), Privacy Rule and the Privacy Act of 1974.

    Copies of medical records not picked-up within 30 business days of the date of this request date will be destroyed and a new Authorization to Request for Information may need to be submitted again.

    I understand that I may revoke this authorization in writing by submitting the request at any time to Saban Community Clinic’s Medical Records Department, otherwise this authorization is valid for 1 full year from the date it was signed.

    This authorization will expire on (you have the option to change the expiration date)