Home » Authorization for Disclosure
I hereby authorize the Center for Fetal Medicine and Women’s Ultrasound to use and disclose health information concerning
Health information may be disclosed(as follows):Any and all health information other than psychotherapy notes may be released, including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records, if any, except as specifically provided below.
The information is used only for the following purposes (e.g., Send report and testing results to my OB) [Note: If you do not want to list the purpose, write down “at the request of the individual”]
(identify specific date not to exceed one-year from today’s date).
I understand that I may revoke this authorization at any time by notifying the Center for Fetal Medicine and Women’s Ultrasound inwriting. My revocation will not affect actions taken by the medical practice prior to its receipt. I understand that, under California Law, that all recipients of health care information are prohibited from re-disclosing it except as required or permitted by law. I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected. A copy of my identification is attached. If completed by a personal representative, legal documentation of sch is attached.
6310 San Vicente Blvd,
Los Angeles, CA 90048
Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
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2001 Santa Monica Blvd,
Santa Monica, CA 90404