--------------------------------Date of Birth: ---------SociaI Security#--------------Patient Name:
Date(s) of Treatment Requested:---------- --------------­
Purpose of Request (Check where appropriate):
p Patient Care
O Self (tee
0 Proxy Patient Portal
requir�d)
O Insurance O Other: --------------
Fees: __ (Please lnitialj - I acknowledge that there will be a moderate fee charged for copies.
I further understand that if records are sent to a physician all fees will be waived.
OI
hereby authorize:-=--�----,..,.-..,.....,._,--,,,,_--....,...,....-,-- to release my health information to:
OI
hereby authorize SVH to allow Proxy Access to my Patient Portal to:
1specify name of hospital or healthcare provider)
---------------------- Phone:----------Address:_.---------------- ----­ Fax: -----------Name:
City:
-------------- State: ---------
I authorize the release of the following records:
0 Discharge Summary
O History & Physical
0 Operative Report
D Consultation Report
Zip:
D Lab Reports
D Basic Data Set
------,------
0 X-Ray Reports
D Other:- --------------------------------I further authorize the release of my (please initial where applicable):
Results of blood test for HIV
__ Alcohol and/or drug abuse
__ Psychiatric Records
This authorization is effective immediately and shall remain in effect until---- -----­
(termination will be 90 days from the date signed if not specified herein). I understand that the
. recipient may not further disclose the health information unless another authorization is obtained
from me or unless such disclosure is specifically required or permitted by law. I understand that I
have a right to receive a copy of this authorization upon my request. I understand I have a right to
revoke this authorization in writing.
Signature
Date
lime
Legal Relationship {documentation may be required)
Simi Valley Hospital
1111111 [llll 1 111 1 111111
"'112*
-�ventist llS7� N. syc.mor• Or.
Health
s1m1 Valley. CA 93005
(805) 955-6QOO
AUTHORIZATION TO
RELEASE OR INSPECT PATIENT
HEALTH INFORMATION
PATIENT INFORMATION
Glendale Adventist
Medical Center
Simi Valley Hospital
..,,\dventist
-Adventist
Health
Health
PLEASE INCLUDE A COPY OF YOUR PICTURE
IDENTIFICATION OR THE AUTHORIZATION WILL NOT BE
VALID
If you are requesting copies of your medical records please note and provide
the following:
o There is a charge of $24.00 pre-payment plus .10 cents per
page
o May take up to 14 working days to process
o We will need a copy of the requested patient's and the
requestor's valid ID
If you need copies to further your health care, we can forward the copies
to your physician or health care provider.
o We will handle the request as a courtesy without charge.
o You must provide the mailing address, phone and fax of the
recipient
For Radiology please contact them directly:
GAMC: 818-863-4185
Glendale Adventist Medical Center
Health Information Management
1509 Wilson Terrace
Glendale, CA 91206
818-409-8171
818-545-1872 fax
SVH: 805-955-6360
Simi Valley Hospital
Health Information Management
2975 Sycamore Drive
Simi Valley, CA 93065
805-955-6820
805-955-6824 fax