Record release from WHHC (English)

Authorization To Release Health Information

Patient Name(Required)
Date of Birth(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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West Hills Healthcare Clinics participation in Comprehensive Primary Care Plus (CPC+) is ending. Beginning in 2022 we will be participating in a new program to enhance your care, Primary Care First.