Center for Reproductive Health & Gynecology

FAX request to: 310.360.9827

AUTHORIZATION FOR ACCESS TO HEALTH INFORMATION

This authorization allows CRH&G/Sam Najmabadi, M.D. to release confidential medical information and records.

NOTE: Information and records regarding treatment of HIV, psychiatric/mental health conditions, or alcohol/substance abuse need additional authorization (see next).

INSTRUCTIONS:

Please complete this form if you would like: (check one) *

To obtain copies of your CRH&G patient medical records.

To have CRH&G send records to: (select this option to fill out)

Request a copy of your medical record to be made available to CRH&G and Faxed to 310.360.9827 from: (select this option to fill out)

Have CRH&G send records to: *

FAX

Request a copy of your medical record to be made available to CRH&G and Faxed to 310.360.9827 from: *

PATIENT INFORMATION:

Full name of patient: *

Date of birth *

Daytime phone number *

Treatment date(s): *

INFORMATION THAT MAY BE RELEASED:

Select which informations you would like to be released:

General Medical Information

HIV Test Results

Alcohol/Drug Related

Mental Health/Psychiatric Records

Today's Date *

Signature *

Clear

INFORMATION REQUESTED:

Select all that apply: *

Consultation and Physician Progress Notes

Laboratory/Pathology Reports/Ultrasounds

General Medical Information

Other

If selected "Other" please specify below:

AUTHORIZATION:

Other Record, I hereby authorize:

to furnish to CRH&G the information as indicated above in my selection.

I hereby authorize CRH&G to provide: *

information as indicated above by my selection.

****There is a fee of $0.50 per page for records copied.

****There is a fee of $6.50 for records being release electronically.

Patient's signature *

Clear

Date *

Note:

Our charts include information on both the patient and a partner. If this applies to you, a Partner's Signature is also needed.

Partner's signature

Clear

Date

PLEASE ALLOW 3-5 DAYS FOR REQUEST