AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

I voluntarily authorize and direct the health care providers named below to disclose and/or request my health information during the term of this authorization. This authorization shall be effective immediately and remain in effect while the providers listed below continue to be involved in my care.

PROVIDERS:

Ian M. Purcell, M.D., Ph.D.

Monali Patel, M.D.

(Requested records are to be sent to or from any of the clinic locations listed below)

7625 Mesa College Dr., Ste. 200A

San Diego, CA 92111

Phone: 858-223-2172

Fax: 858-682-2205

Records may be released to or requested from any current or previous physicians involved in my medical care.

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

I understand that by signing this agreement, the providers listed above have my consent to release and/or request medical records for all dates including all diagnostic tests of any type and reports, history, hospitalization, diagnosis, prognosis, treatment, medication and pharmacy records, correspondence, consults, statement of charges or expenses. Any and all reports of any type or character.

I understand that once my health care provider discloses my health information, my health care provider cannot guarantee that the recipient will not disclose my health information to a third party. The third party may not be required to abide by this authorization or applicable federal and state law, governing the use and disclosure of my health information. I understand that I may revoke this authorization at any time for any reason with a written notice.

X

Call us at (858)-223-2172
to schedule an appointment

Medical Record Request

Release of records includes a $25 charge, which is payable via check or credit card. After submission, an invoice will be sent to the email address provided with instructions.

Please note that we do not keep any X-rays or Imaging on file
View
All of my medical information that the provider has in his/her position, excluding: mental healthdiagnosis and HIV diagnosis/treatment.


I also choose to consent the release of my:
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