Record release from WHHC (English)

Authorization To Release Health Information

Patient Name(Required)
Date of Birth(Required)
Address(Required)
Check the spaces below to specifically authorize the release of the following health information and/or records, if such information and/or records exist(Required)
Each of the following items MUST BE CHECKED to be included in the use or disclosure of other health information:
Except to the extent that action has already been taken in reliance upon this authorization, I understand that I may revoke this authorization at any time by giving written notice to West Hills Healthcare Clinic.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, enrollment or eligibility for benefits. I may inspect or copy any information to be used or disclosed under this authorization.

I also understand that, if the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing my information under the applicable state or federal law and regulations.

I further understand that the person(s) I am authorizing to use or disclose my information may receive compensation (directly or indirectly) for doing so.
Signature of individual(Required)
MM slash DD slash YYYY
Signature of Legal Representative

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