HIPAA Certified Professional
Certification #1645680

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Jesus Rios Courier LLC
dba Rapid Med Retrieval Sacramento
HIPAA-Compliant Authorization Form
This form complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule and authorizes the release of protected health information.
SECTION 1: PATIENT INFORMATION
SECTION 2: RELEASE MEDICAL RECORDS FROM
SECTION 3: RELEASE MEDICAL RECORDS TO
Jesus Rios Courier LLC dba Rapid Med Retrieval Sacramento
On behalf of:
SECTION 4: DATES OF SERVICE

I authorize the release of medical records for the following time period:

to:
SECTION 5: INFORMATION TO BE RELEASED

I authorize the release of the following medical information (check all that apply):

Special Categories (Check if applicable)

The following types of information require specific authorization and will ONLY be released if checked below:

SECTION 6: PURPOSE OF DISCLOSURE

The purpose of this disclosure is (check one):

SECTION 7: EXPIRATION OF AUTHORIZATION

This authorization will expire (check one):

PATIENT RIGHTS AND ACKNOWLEDGMENTS

I understand and acknowledge the following:

  • I have the right to revoke this authorization at any time by providing written notice to the healthcare provider listed in Section 2. However, revocation will not apply to information already released.
  • I understand that my treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization, except as permitted by law.
  • Once my health information is disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
  • I have the right to inspect or copy the health information to be disclosed as permitted by law.
  • I have the right to receive a copy of this authorization.
  • The healthcare provider may charge reasonable fees for copying and mailing records as allowed by California law (maximum $0.25 per page for paper copies).
  • Jesus Rios Courier LLC dba Rapid Med Retrieval Sacramento is acting as an authorized representative to obtain these records on behalf of the individual/entity listed in Section 3.
SIGNATURE

I certify that I have read and understand this authorization and that I am the patient or am authorized to act on behalf of the patient. I hereby authorize the release of medical information as specified above.

(Sign in ink if printing)

If signed by someone other than the patient, please complete below:

FOR OFFICE USE ONLY
Jesus Rios Courier LLC dba Rapid Med Retrieval Sacramento
HIPAA Certified Professional - Certification #1645680
Servicio bilingüe disponible | Bilingual service available
This form complies with HIPAA Privacy Rule 45 CFR § 164.508 and California Health & Safety Code § 123110