Diabetes Wellness Workshop

Completion of this document authorizes the disclosure and/or use of health information about your health record. Failure to provide all information requested may invalidate this Authorization.

YOUR INFORMATION

Date of Birth*

Other Name(s) Used

Phone*

Email*

Recipient Name*

Phone Number*

Fax Number

VCC Location*

I authorize VCC to obtain a copy of my Medical Records from:

Name of Facility/Provider/Person:*

Phone #*

Fax #

INFORMATION TO BE RELEASED

The dates of service I am requesting are If no date is entered, only the most recent 6 months will be released.

The dates of service I am requesting are

From:
MM slash DD slash YYYY

To:
MM slash DD slash YYYY

From:*
MM slash DD slash YYYY

To:*
MM slash DD slash YYYY

Other:*

AUTHORIZATION TO RELEASE PROTECTED INFORMATION

Special authorization is required to release sensitive information. In some instances, a patient's clinician, psychiatrist, or social worker may also be required to approve your request.

Special authorization is required to request sensitive information.

Initial - Acquired Immunodeficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV) Testing and Treatment Information*

Initial - Alcohol/Drug Treatment Information*

Initial - Behavioral Health or Mental Health Treatment Information*

PURPOSE OF REQUESTED USE OR DISCLOSURE

Transfer of Care (please specify):*

Other (please specify):*

MY RIGHTS AS A PATIENT
I have a right to receive a copy of this Authorization in addition to the health information that I am requesting.

I may revoke this authorization at any time, but I must do so in writing. The revocation must be signed by me or on my behalf, and submitted to the following address: VCC, Attn: Medical Records, 465 La Tortuga Drive, Vista, CA 92081.

My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization.

If I have authorized the disclosure of my health information to someone not legally required to keep it confidential, it may be re-disclosed and may not be protected. California law prohibits the requestor from making further disclosure of my health information unless the requestor obtains another authorization from me or unless such disclosure is specially required or permitted by law.

This Authorization expires on

If no date is given, this authorization will expire 12 months from the signature date

Expiration Date:
MM slash DD slash YYYY

Signature*

Signature Date*
MM slash DD slash YYYY

Legal Representative Signature*

Legal Representative Signature Date
MM slash DD slash YYYY

If signed by someone other than the patient, state your legal relationship to the patient:*

Date/Time

Description