Authorization For Release of Medical Information Authorization for Release of Medical InformationI request access as the:* Patient Parent/Guardian Medical Power of Attorney Upload a copy of the Power Of Attorney*Accepted file types: pdf, doc, docx, Max. file size: 256 MB.Name of Patient* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 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 Requesting Records FromName of Medical Office/Provider* Phone*FaxSend Records ToName of Medical Office/Provider* Phone*FaxCalifornia law (AB610) allows the healthcare provider a 15-day turnaround time from the date a request is received in order to process a patient's request for copies of their medical records. Raffi Tachdjian MD turn-around time is about 10 business days. General medical records may include information of diagnosis and/or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This may include information and treatment of mental illness and the use of alcohol, drugs and tobacco, but excludes psychotherapy notes.I would like the following information sent* All general medical information on file General medical information between certain dates Other Details List the date range*Date from (mm-dd-year)Date to (mm-dd-year)Please specify*Duration: This authorization will expire 12 months from the date signed. Right to Copy: I have a right to receive a copy of the Authorization after I sign it. Revocation Process: I understand that i amy refuse to sign or may revoke (at any time) this authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment at Raffi Tachdjan, MD. Re-Disclosure Statement: I understand that once Raffi Tachdjan, MD discloses my health information to the recipient, Raffi Tachdjan, MD cannot guarantee that the recipient will not re-disclose my health information to a third party. The third party may not be required to abide by their authorization of Applicable law governing the use and disclosure of my health information. I have read and understand the terms of this authorization and I have had an opportunity to ask questions about the use and disclosure of my health information. By my signature below, I hereby, knowing and voluntarily, authorize Raffi Tachdjan, MD to use or disclose my health information in the manner described above.Signature* Reset signature Signature locked. Reset to sign again EmailThis field is for validation purposes and should be left unchanged.
