Authorization for Disclosure of Medical Information from another Doctor

Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INFORMATION
PATIENT FULL NAME*
PHONE*
DATE OF BIRTH*

MonthDayYear
Date
ADDRESS*
CITY*
STATE*
ZIP*
I AM REQUESTING MEDICAL RECORDS TO BE RELEASED FROM: (MEDICAL ORG/PHYSICIAN NAME)
NAME*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
PHONE*
FAX#*
Please enter a valid phone number.
I authorize this information to be released to JON J. ATIGA M.D., INC at 25405 HANCOCK AVE. Ste. 108 Murrieta, Ca 92562.

Information to be disclosed/released includes (Please initial)
ENTIRE RECORD

Clear
SUBSTANCE ABUSE

Clear
PSYCHIATRIC/MENTAL HEALTH INFO.

Clear
AIDS/HIV INFO.

Clear
SPECIFIC INFORMATION (Specify date of service, vaccines, lab results, x ray results, etc.)
Date*

MonthDayYear
Date
TERMINATE THIS AUTHORIZATION BY SUBMITTING A WRITTEN REVOCATION TO JON J. ATIGA M.D., INC.
SIGNATURE OF PATIENT (legal guardian)*

Clear
Please print your name.
RELATIONSHIP TO PATIENT*
DATE*

MonthDayYear
Date
25405 Hancock Ave. Ste. 108 Murrieta, Ca 92562

(951) 304-7854 Fax (951) 304-7855
Should be Empty:

Jon J. Atiga M.D., Inc. Pediatric and Adolescent Medicine