Request for Medical Records

Tuolumne Me-Wuk Indian Health Center (TMWIHC)
HIPAA authorization to disclose protected health information (PHI)

TMWIHC cannot disclose PHI without a valid authorization from the patient (or patient’s representative) that the information is about. This request does not allow your designated person to make any of your treatment or direct care decisions. Failure to fill out this form completely may cause a delay in acting on your authorization.

Patient Information

Last Name(Required)

First Name(Required)

Middle Initial

Patient Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Your Email Address(Required)

Daytime Phone

Evening Phone

Date of Birth(Required)

I authorize TMWIHC to speak to the following personal representative regarding (check one):(Required)

All medical information, including but not limited to records pertaining to examinations, treatments, consultations, billing records, x-rays and reports, history, laboratory findings, admissions and discharge reports, treatment records, diagnosis and prognosis and records, nurse’s and doctor’s notes and other non-medical information in my file.

Only the following types of information:

List the types of information to authorized to discuss:

Records Release Information To:

Person Authorized to Receive Information (one individual per form)

Last Name

First Name

Birth Date

Relationship to Patient

Phone

Records Request Information From:

Person Authorized to Receive Information (one individual per form)

Last Name

First Name

Birth Date

Relationship to Patient

Phone

I understand that as a health care provider TMWIHC is required to protect the privacy of my PHI under federal and related state laws. By agreeing to have my PHI released to another party, my PHI will no longer be protected by HIPAA, and it may be discussed and/or released by them without my permission.

The following items require special authorization by law.

Check the box below to include disclosure:

Special Authorization

I understand that this authorization will expire twelve (12) months from the date of my signature as noted below unless I:

Revoke the authorization in writing by presenting or mailing a revocation to TMWIHC. I understand that the revocation will not influence any actions taken prior to the date my revocation is received and processed by TMWIHC.
Request a different date as noted below within 12 months. I wish to request my authorization to expire on the date noted here .

Signature

Who will be signing this request for medical records?(Required)

Patient

Legal Representative

I have read and understand the request and acknowledge that by signing this form I have the legal authority to act on behalf of the patient and am attaching the appropriate legal documentation to this request:

Patient Full Name

Patient Signature Date

I have read and understand the above information. I acknowledge that by my signature I am voluntarily authorizing TMWIHC and its affiliates to use and/or disclose my PHI to the person designated above.

Legal Representative Full Name

Legal Representative Signature Date

Mailing address:
Tuolumne Me-Wuk Indian Health Center- Medical Records
18880 Cherry Valley Blvd.
Tuolumne, CA 95379

Phone Number: 209-928-5400 (Opt. 1 for Primary Care than Opt. 5 for Medical Records)
Fax Number: 209-928-5411

Request for Medical Records

Tuolumne Me-Wuk Indian Health Center (TMWIHC)
HIPAA authorization to disclose protected health information (PHI)

Patient Information

Records Release Information To:

Records Request Information From:

The following items require special authorization by law.

I understand that this authorization will expire twelve (12) months from the date of my signature as noted below unless I:

Signature

Nearby 24-Hour Emergency Rooms:

Quick Links

Request for Medical Records

Tuolumne Me-Wuk Indian Health Center (TMWIHC) HIPAA authorization to disclose protected health information (PHI)

Patient Information

Records Release Information To:

Records Request Information From:

The following items require special authorization by law.

I understand that this authorization will expire twelve (12) months from the date of my signature as noted below unless I:

Signature

Quick Links

Tuolumne Me-Wuk Indian Health Center (TMWIHC)
HIPAA authorization to disclose protected health information (PHI)