AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION DR#(Required) Patient Name(Required) Date of Birth Month Day Year Purpose of Release AT THE REQUEST OF THE PATIENT/PATIENT’S REPRESENTATIVE TO RELEASE MEDICAL INFORMATION TO THE IRVINE POLICE DEPARTMENT FOR INVESTIGATIVE PURPOSES OTHER: Purpose of Release: Other Medical Facility Which Records Shall Be Release From CHILDREN’S HOSPITAL OF ORANGE COUNTY HOAG MEMORIAL HOSPITAL MISSION HOSPITAL KAISER PERMANENTE ANAHEIM MEMORIAL MEDICAL CENTER OC GLOBAL ST. JOSEPH’S HOSPITAL SADDLEBACK MEMORIAL MEDICAL CENTER OTHER: Medical Facility – Other Party to Receive Records(I authorize the facility above to release records to)Name Of Facility To Receive Health Information Name/Title Of Person To Receive Records(Required) PhoneAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information to be Released DISCHARGE SUMMARY BILLING STATEMENTS PATHOLOGY REPORTS EKG PROGRESS NOTES LABORATORY REPORTS DENTAL RECORDS OPERATIVE REPORTS RADIOLOGY REPORTS ALL RECORDS AND REPORTS EMERGENCY MEDICINE REPORTS HISTORY AND PHYSICAL EXAMS DIAGNOSTIC IMAGING REPORTS CONSULTATIONS OUTPATIENT CLINIC RECORDS OTHER: Information to be Released – Other Limitations On Use Of Medical InformationMedical information released pursuant to this Authorization shall specifically be used for: Specific AuthorizationsThe following information will not be released unless you specifically authorize it by initialing the relevant item(s) below. I specifically authorize the release of information: Pertaining to drug and alcohol abuse diagnosis or treatment (42 Code of Federal Regulations § 2.34 and 2.35) Pertaining to mental health diagnosis or treatment (Welfare and Institutions Code §5328, et seq.) Of HIV/AIDS testing information (Health and Safety Code § 120980(g)) Of genetic testing information (Health and Safety Code § 124980(j)) NOTICE: Medical Facilities and many other organizations such as physicians, hospitals and health plans are required by law to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws. MY RIGHTS: I understand this authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization except if the authorization is for: 1) conducting research-related treatment, 2) obtaining information in connection with eligibility or enrollment in a health plan, 3) determining an entity’s obligation to pay a claim, or 4) creating health information to provide to a third party. Under no circumstances, however, am I required to authorize the release of mental health records. I may revoke this authorization at any time, provided that I do so in writing and submit it to the above listed medical facility. The revocation will take effect when the above medical facility receives it, except to the extent that the above medical facility or others have already relied on it. I am entitled to receive a copy of this Authorization. EXPIRATION OF AUTHORIZATION:Unless otherwise revoked, this Authorization expires (Specify applicable date or event). If no date is indicated, this Authorization will expire twelve (12) months after the date of signing this form.Signature Of Patient Or Patient's Legal RepresentativeDate MM slash DD slash YYYY Print Name Relationship Time Hours : Minutes Witness Or Translator FOR MINORS:(To be completed if Authorization is signed by parent or guardian of minor) I am the parent or guardian of (name)a minor, whose records are to be furnished only for the purpose of Officer Name Badge # Enter an email address to send a copy of this completed form to:(Required)