Authorization For Disclosure of Health Information
Place Patient Label Here
↓Legal Name (Last, First)
Date of Birth (MM/DD/YYYY)
↓E-mail Address
USC ID Cell
Telephone
Home Phone
I hereby authorize the use and disclosure of protected health information: ↓ Release records: From or To ↓ Release records: From or To Self Health Care Provider Other: ↓Recipient Name (Last, First)
USC Student Health
Parent/Legal Guardian
↓Street Address
1031 W. 34th Street, Suite LL-106 Los Angeles, California 90089
↓City
Phone: (213) 740-0206 Fax: (213) 740-4961 Email: eshchim@usc.edu
State
↓Telephone Number
Zip Code
Fax Number
↓Email Address
Delivery Method:
Pick-Up*
Fax
* I understand that if I do not pick up records within 5 business days, USCSHC will shred my records and I may have to start the process again.
The requested information is to be used for the following purpose: ________________________ Information requested: Records dated from ___/___/___ to ___/___/___ MM
DD
YY
MM
DD
YY
All Medical Records *(Fees may be applicable, please see page 2) Athletic Medicine Records X-ray: Report Image(s), choose format: Digital CD Counseling Records Psychiatric Records CARE-SC (Confidential Advocacy, Resources, and Education – Support Center) formerly known as Relationship and Sexual Violence Prevention and Services (RSVP)
Other health record: _________________________________________________________ In compliance with California Statues which require special permission to release privileged information; please check the box and initial if any of these conditions are applicable. ____Mental Health/Psychiatric ____HIV/AIDS ____Drug/Alcohol Treatment/Evaluation Initial
Initial
Initial
This authorization is effective immediately and shall remain in effect for one (1) year for mental health records or until: ____/___/___ (date). MM
DD
YY
I may revoke this request at any time. My cancellation will be effective when it has been received in writing by USCSHC. My revocation must be signed by me and delivered to the address, email, or fax at the bottom of the page. Signature of Patient _____________________________________ Date: _______________ ID Note: You must submit government-issued ID with this authorization for verification purposes.
If patient is a minor or is otherwise unable to sign, please state relationship: __________________ HIM Use Only Comment:
Disclose By:
Date:
1031 W. 34th Street, Suite LL106, Los Angeles, California 90089 • (213) 740-0206 • FAX (213) 740-4961 • Email: eshchim@usc.edu HIM_ROIAUTH_101624_F
Page 1 of 2