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Medical Record Authorization Form Instructions

Medical Record Authorization form InstructionsMarch 20211 | Page Important: Please download and save a copy of this form before filling it out. How to Complete the Medical Record Authorization form Are you the patient?oAnswer Yes if you are the patient or No if you are the patient s legal or personal representative. NOTE: If you answer No, I am the patient s legal/personal representative , you may be asked to providesupporting documentation that gives you the authority to request Medical records on the behalf of the patient.

California Pacific Medical Center: Transplant Program, San Francisco . PO Box 619091 : Roseville . CA : 95661 (916) 736-5435 : S3AMBROIDept@sutterhealth.org California Pacific Medical Center: Whitney Clinic, San Francisco . PO Box 619091 – –

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