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Authority for Release of Medical Information

Medical Authorization Form For Adults In San Jose

Category:

Releases and Waivers - Medical

State:

Multi-State

City:

San Jose

Control #:

US-00426

Format:

Instant download

Description

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.

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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 • 408-885-5770. 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.

Medical Authorization Form For Adults In San Jose

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