Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Authorization Form For Adults In San Jose
Category:
State:
Multi-State
City:
San Jose
Control #:
US-00426
Format:
Word;
Rich Text
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Download, print and complete the authorization form. The authorization form must be signed and dated.To do this, Santa Clara Valley Medical Center (SCVMC) requires a completed and signed form before we can release the records to anyone, including the patient. Administration • 828 S. Bascom Ave. , Suite 200, 2nd Fl., San Jose, CA 95128 • . Instructions: Fill in the appropriate information in each applicable section. Sign, date, and return the form. Submit Your Authorization Form(opens in a new tab). Do not use for patient copies of or access to their medical records. Patients should go to kp.