036 151
User Manual: 036
Open the PDF directly: View PDF 
.
Page Count: 2
AUTHORIZATION TO RELEASE PROTECTED
HEALTH INFORMATION
151-036 (3-17) Page 1 of 2
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?
UC San Diego Health Other: _______________________________________________________
Address/City/State/Zip
Phone Fax (Urgent Patient Care only)
Release
Records to:
Where do you want
records sent?
Who do you want to
receive records?
Name of Hospital/Clinic/Persion
Street Address/City/State/Zip
Phone Fax (Urgent Patient Care only)
Purpose: Continued Care – Appointment Date (if known): _____ / _____ / ________
Legal Personal Insurance Disability
Other (please specify):
Health
Information to
be Released:
What do you want
sent or released?
Routine Record Sets – For dates of service: _____________________________________
Hospital Stay (History and physical, operative report, discharge summary, progress notes, lab, radiology reports)
Clinic visit (ofce notes, procedure notes, operative notes, lab, diagnostic and radiology results)
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 benets 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: On Date:
Patient Identication
*Hospital & Clinic staff:
Afx patient label here. If providing
records to the patient, update the
Staff Use section of the form and
update Quick Disclosure.
*151-036*
COMPLETING AUTHORIZATION TO RELEASE
PROTECTED HEALTH INFORMATION
151-036 (3-17) Page 2 of 2
Patient Identication
*Hospital & Clinic staff: Afx 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.
To protect our patient’s condential medical information we must have a valid, complete and legible
authorization to disclose their health information.
All sections of this authorization must be completely lled 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 condential. If you have
authorized the disclosure of your health information to someone who is not legally required to keep it
condential, it may no longer be protected by state or federal condentiality 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 ve (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
fteen (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 rst 20 pages are at no
cost and after the 20th page there will be charge of $0.25 per page.
Radiology Image Fees:
The rst 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).
