REQUEST FOR PATIENT ACCESS TO MEDICAL RECORDS
I hereby request (name of physician, hospital or other healthcare provider)
, to give me access to medical information for (patient’s
name) .
SCOPE OF ACCESS REQUESTED
I would like access to: G All the records or
G The portion of the records concerning:
(Specify type of disease, accident, dates of treatment, other portion of […]
DOCUMENTATION OF SELF-SUFFICIENT MINOR STATUS
For the purposes of obtaining medical, dental or surgical diagnosis or treatment, pursuant to Family
Code §6922, I hereby certify that the following is true:
1. I am fifteen years of age or older, having been born on ___________, at __________________
(date) ________________________________________________________________________.
(Location)
2. I am living separate and apart from my parents or legal […]
Caregiver’s Authorization Affidavit
Use of this affidavit is authorized by Part 1.5 (commencing with §6550) of Division 11 of the
California Family Code.
Instructions : Completion of items 1–4 and the signing of the affidavit are sufficient to authorize
both enrollment of a minor in school and school-related medical care. Completion of items 5–8 is
additionally required to authorize any […]
AUTHORIZATION TO TRANSFER MEDICAL RECORDS
I hereby authorize , M.D., to furnish medical information
concerning [patient’s name:] to Dr. [physician’s name and
address:] .
Any and all information may be released, including, but not limited to, mental health records protected by
the Lanterman-Petris-Short Act, drug and alcohol abuse records, and HIV test results, if any, except as
specifically provided below:
[Optional:] I […]
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I hereby authorize , M.D. to furnish medical information
concerning (patient) to
(name and address of person to receive records).
Any and all information may be released, including but not limited to mental health records protected
by the Lanterman-Petris-Short Act, drug and/or alcohol abuse records and/or HIV test results, if any,
except as specifically provided […]
AUTHORIZATION FOR AGENT
TO CONSENT TO MEDICAL TREATMENT […]