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User Manual: 036

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*151-036*
AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION

*Hospital & Clinic staff:
Affix patient label here. If providing
records to the patient, update the
Staff Use section of the form and
update Quick Disclosure.
Patient Identification

Patient
Information:

Patient Name

Nickname/Maiden/Other

Address/City/State/Zip
Date of Birth

Last 4 of SSN#

Phone

_____ / _____ / ________

Record
Holder:
Who has the
information you
want released?

Release
Records to:

 UC San Diego Health
Address/City/State/Zip
Phone

Fax (Urgent Patient Care only)

Name of Hospital/Clinic/Persion

Where do you want Street Address/City/State/Zip
records sent?
Who do you want to Phone
receive records?

Purpose:

 Other: _______________________________________________________

Fax (Urgent Patient Care only)

 Continued Care – Appointment Date (if known): _____ / _____ / ________
 Legal		
 Personal
 Insurance
 Disability
Other (please specify):

Health
Routine Record Sets – For dates of service: _____________________________________
Information to  Hospital Stay (History and physical, operative report, discharge summary, progress notes, lab, radiology reports)
be Released:
 Clinic visit (office notes, procedure notes, operative notes, lab, diagnostic and radiology results)
What do you want
sent or released?

 Other Records – Please Specify Type: ______________________________________________________
 Billing Records
 Radiology Images (only)  Mail
 Pick-up
 Email** (See bottom of page 2 for email limitation)

Sensitive
Information:

Sensitive information WILL BE RELEASED unless you tell us not to by initialing below:
______ Do Not Release Drug & Alcohol abuse treatment records
______ Do Not Release Mental Health/Psychiatric treatment records
______ Do Not Release HIV Test Results
______ Do Not Release Genetic Test Results

Authorization I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits may not
be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related
treatment, 2) to obtain information in connection with eligibility or enrollment in a health plan, 3) to determine an
entity’s obligation to pay a claim, or 4) to create health information to provide to a third party.
I understand this authorization may be revoked in writing at any time except to the extent that action had been taken
in reliance on this authorization. Unless otherwise revoked this authorization will expire 12 months after the date of
signing this form.
_______________________________________________ __________________________________ _______________ ____________ AM/PM
Signature of Patient or Authorized Representative
Print Name
Date
Time
________________________________ _________________________________ __________________ ______________ ____________ AM/PM
Relationship (If signed by other than Patient) If Interpreted: Signature OR ID of Interpreter
Language
Date
Time
 Telephone
 Video

*Staff Use

Info Released By:

151-036 (3-17) Page 1 of 2

On Date:

COMPLETING AUTHORIZATION TO RELEASE
PROTECTED HEALTH INFORMATION

*Hospital & Clinic staff: Affix patient
label inside this box and indicate if
records have been provided to the
patient in the Staff Use section at the
bottom of the form.
Patient Identification

To protect our patient’s confidential medical information we must have a valid, complete and legible
authorization to disclose their health information.
All sections of this authorization must be completely filled out before UC San Diego Health is
permitted to disclose your protected health information.
Notice:
UC San Diego Health and many other organizations and individuals such as physicians, hospitals
and health plans are required by law to keep your health information confidential. If you have
authorized the disclosure of your health information to someone who is not legally required to keep it
confidential, it may no longer be protected by state or federal confidentiality laws.
Revocation:
A revocation/cancellation of this authorization can be provided at any time in writing to:
UC San Diego Health
Health Information Management
200 W Arbor Drive, #8825
San Diego, CA 92103-8825
Patient’s rights:
Under California Health and Safety Code any adult patient, a minor patient authorized by law to
consent to his or her own treatment, or the patient’s legal representative, (i.e., a parent, guardian,
conservator, or personal representative of a deceased patient) has a right to access the clinical
record. As per Section 123110, if the patient or representative requests to inspect the record, the
request to inspect must be in writing and the record must be made available during regular business
hours within five (5) working days after the request is received. If the patient wants a copy of all or
part of the record, the request for copies must be in writing, and copies must be provided within
fifteen (15) days after receiving the request. Under the code, providers may recover up to $0.25 per
page for the cost of copying the record, as well as, the reasonable cost for locating the record and
making the record available.
Medical Record Fees:
There is no charge for records to be sent to another health care provider. Records released directly to
the patient or an authorized family member may be subject to charges; the first 20 pages are at no
cost and after the 20th page there will be charge of $0.25 per page.
Radiology Image Fees:
The first copy is free of charge, $25.00 due for each additional copy unless for a provider.
**PLEASE NOTE: Only the three (3) most recent studies can be mailed electronically (email).

151-036 (3-17) Page 2 of 2
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