Authorization for Use/Disclosure of Health Information

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Last Name*

First Name*

Middle Name*

Date of Birth* Age:

Authorization for Use/Disclosure of Information:

I voluntarily authorize and direct the health care provider named below to disclose my health information during the term of this authorization to the recipient that I have identified below.

Name of Provider*

Address*

Address 2

City*

State*

Zip*

Fax Number*

Recipient and Address for Delivery of Records:

Marin Fertility Center
1100 South Eliseo Drive, Suite 104
Greenbae, CA 94904
Fax Number 415-925-9410

Information to be disclosed:

This authorization permits the above named health care provider to disclose the following medical records.

All fertility medical records that the provider(s) and office has in his, her or their possession, including information relating to any medical history, mental or physical condition and any treatment received by me, including without limitation, lab tests, imaging studies, HIV/AIDS status, genetic testing, psychotherapy notes and other mental health information and records from my other health care providers that the above-named health care provider may hold. Specific records to INCLUDE are hysterosalpingogram, saline sonogram, ultrasound(s), hysterocopy, hormone testing, semen analysis, prior intrauterine insemination(s), prior IVF cycle(s) including stim sheets and cycle details from the embryology laboratory.

Special medical records request

Term:

This Authorization will remain in effect for one (1) year from the date this authorization is signed.

ReDisclosure:

I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party many not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

Refusal to sign/right to revoke:

I understand that I may refuse to sig or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.

Revocation:

I understand that the Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider at my health care provider's regular office address. The revocation will be effective immediately upon my health care provider's receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before the provider received by written notice of revocation.

Questions:

I may contact my health care provider for answers to my questions about the privacy of my health information at my health care provider's regular office telephone number. I understand that I have the right to receive a copy of this authorization from my health care provider.

Photocopy:

A photocopy, fax or electronic copy of this authorization shall be considered as effective and as valid as original.

Signature*

(Reset Signature)

Date*

Full Name*

Authorization for Use/Disclosure of Health Information

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