AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I Authorize: Health Information Department
UCD Women’s Center For Health
Folsom, CA 95630
From: Name: _________________________________________
DOB: _________________________________________
I have previously received care at the Women’s Center for Health, Folsom. I authorize UCDHS at my own request to release my medical records for the purpose of continuity of my health care. Please promptly provide to my doctor at the address below the information as listed below. This authorization is completely voluntary. This authorization may be revoked at any time (supplied in writing to addressee). I have kept a copy of this authorization. Unless otherwise revoked, this authorization will expire one year after the date of signature.
· a Clinical Summary: including information that may include (initial lines:
_______ HIV test results (Health & Safety Code 120980(g)).
_______ Genetic testing information (Health & Safety Code 124980(j))
· a copy of my most recent pap smear report
· a copy of my most recent mammogram report
· a copy of my most recent pelvic ultrasound report (if available)
·
a copy of my most recent complete visit
with my gynecologist
·
a copy of an episode review for each pregnancy
available in EMR
Please release this health information by mailing it to:
Dr. Ruth Haskins
Folsom, CA 95630
Print Name: _______________________________________________
Signed: _______________________________________________
Date: ________________________ Time: ______________