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Record release from WHHC (English)
Authorization To Release Health Information
Date of Birth
I authorize West Hills Healthcare Clinic to release my health information that I have identified below to:
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
For the purpose of
Expires in 180 days or
Check the spaces below to specifically authorize the release of the following health information and/or records, if such information and/or records exist
Transcribed hospital reports
Medical records needed for continuity of care
Most recent five-year history
Emergency and urgent care records
Clinician office chart notes
Diagnostic imaging reports
Each of the following items MUST BE CHECKED to be included in the use or disclosure of other health information:
HIV / AIDS related health information and/or records
Mental health information and/or records
Genetic testing information and/or records
Drug/Alcohol diagnosis, treatment and/or referral information (Federal regulations required a description of, and what kind of information is to be disclosed):
Psychotherapy notes (If this authorization is for the use and/or disclosure of psychotherapy notes, then it cannot be combined with another authorization).
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
MM slash DD slash YYYY
Signature of Legal Representative
Description of Legal Authority
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