AUTHORIZATION FOR RELEASE OF HEALTH …

1 I authorize_____(Name of person or facility which has information - example: UCSF/Mt. Zion)to RELEASE HEALTH information to:_____Name of person or facility to receive healthinformation (full address)_____Street address:_____City, State, Zip Code_____Please specify the HEALTH information you authorize to be released:Type(s) of HEALTH information : _____Date(s) of treatment:_____The following information will not be released unless you specificallyauthorize it by marking the relevant box(es) below: information pertaining to drug and alcohol abuse, diagnosis or treatment ( and ).

2 information pertaining to mental HEALTH diagnosis or treatment (Welfare andInstitutions Code 5328, et seq.) RELEASE of HIV/AIDS test results ( HEALTH and Safety Code 120980(g)). RELEASE of genetic testing information ( HEALTH and Safety Code 124980(j)).EXPIRATION OF AUTHORIZATIONU nless otherwise revoked, this AUTHORIZATION expires _____(insertapplicable date or event). If no date is indicated, the AUTHORIZATION willexpire 12 months after the date of my signing this NameSignature (Patient, Parent, Guardian)Date TimeRelationship to Patient (Parent,Guardian, Conservator, PatientRepresentative)Requested format: Paper CDDATE:PATIENT NAME:BIRTHDATE:ID VERIFICATION (TYPE):ID VERIFIED BY: AUTHORIZATION FOR RELEASEOF HEALTH INFORMATIONAUTHORIZATION FOR RELEASEOF HEALTH INFORMATION756-020Z (Rev.)

3 10/15) WorkflowOne MEDICAL RECORD COPYThe purpose of this RELEASE isfor (check one or more): Continuity of care ordischarge planning Billing and payment of bill At the request of the patient/patient representative Other (state reason)_____NOTICEUCSF and many other organizations and individuals such as physicians,hospitals and HEALTH plans are required by law to keep your healthinformation confidential. If you have authorized the disclosure of yourhealth information to someone who is not legally required to keep itconfidential, it may no longer be protected by state or federalconfidentiality Completed AUTHORIZATION To: HEALTH information Management ServicesUCSF Medical Center400 Parnassus Ave.

4 , Room A88 San Francisco, CA 94143-0308 YOUR RIGHTSThis AUTHORIZATION to RELEASE HEALTH information is voluntary. Treatment,payment, enrollment or eligibility for benefits may not be conditioned onsigning this AUTHORIZATION except in the following cases: (1) to conductresearch-related treatment, (2) to obtain information in connection witheligibility or enrollment in a HEALTH plan, (3) to determine an entity sobligation to pay a claim, or (4) to create HEALTH information to provide toa third AUTHORIZATION may be revoked at any time. The revocation must be inwriting, signed by you or your patient representative, and delivered toHealth information Management Services.

5 The revocation will take effectwhen UCSF receives it, except to the extent UCSF or others have alreadyrelied on are entitled to receive a copy of this AUTHORIZATION .