Gastroenterologist Covina, CA - Reflux, Stomach Pain, Ulcers

Citrus Valley Gastroenterology

MEDICAL RECORDS RELEASE

Date

All your medical information is confidential under state and federal laws. Your medical information cannot be released without signing a Medical Records Release form. Medical information is submitted with claims to evaluate medical necessity

I hereby authorize you to release to any individuals listed below and to my referring doctor any information including the diagnosis and record(s) of any treatment or examination rendered to me.

Send to Referring Doctor

Authorization For listed individual is limited to the following records and type of information:

LIST NAME (S) OF AUTHORIZED INDIVIDUALS SUCH AS: Spouse, Children, Siblings, etc

Name(Print)

Relationship

Date

Name(Print)

Relationship

Date

Name(Print)

Relationship

Date

I understand that the requester may not further use or disclose the medical information unless authorization is obtained from the patient or unless such use or disclosure is specifically required or permitted by law.

Medical records release requested by the patient

To our patients: There may be a fee for the copying of records. The copy fee is based on the size of the chart and is payable at the time of request. Please allow three days for the retrieval and copying of records.

Medical records will be used for:

Follow-up care

Insurance

Attorney

Other

Patient Name (PRINT)

Date Of Birth

Patient Signature
Note:Please use your mouse on desktop and your finger on mobile to sign in the below box.

Clear

Date

About Us

Site Map

Covina Location

500 W. San Bernardino Rd, Suite B Covina, CA 91722

(626) 960-2326
Glendora Location

415 W. Route 66, Suite 102 Glendora, CA 91740

(626) 610-2112