Medical records

Completion of this form authorizes the disclosure and/or use of private health information about you. Please allow up to 10 days after completing the form, for medical records to be released. Personal identification will be required before information can be released. If you are requesting a copy of your bill or itemized statement, please do not use this form, and contact our billing office at 1-877-673-0903.

For inquiries regarding the status of a medical records request, please contact HIM@shchd.org.

Name(Required)

First Last

Phone(Required)

Email(Required)

Previous name used

ie: maiden name

Date of birth(Required)

Social security number

Optional

Release records from(Required)

SoHum Health

Other

Name of other hospital or office(Required)

Address of other hospital or office(Required)

Street Address Address Line 2 City State ZIP Code

Release records to(Required)

SoHum Health

Self

Other

How would you like to receive your medical records?(Required)

Pick-up from Jerold Phelps Community Hospital

Mail printed copies

Encrypted email

Fax

Provide your phone number to contact when ready for pick-up(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Email address(Required)

Fax number(Required)

Name of other hospital or office(Required)

Address of other hospital or office(Required)

Street Address Address Line 2 City State ZIP Code

I am authorizing release of all the following health information pertaining to my medical history, mental or physical condition and treatment received(Required)

Please indicate specific documents being requested below

Lab

Radiology

EKG

Emergency Room Visits

Physician’s notes and reports

Clinic records

Immunizations

Other

Other(Required)

Radiology(Required)

Report only

Imaging only

Report and imaging

Type of radiology service

Optional. Ex: X-Ray, CT, Mammogram, etc.

From(Required)

To(Required)

Are records needed for an upcoming appointment?(Required)

Yes

Appointment date(Required)

I specifically authorize release of the following information

These records will NOT be sent unless checked below

Mental Health information

HIV test results

Alcohol/drug treatment information

The purpose of requested use or disclosure(Required)

Personal

Continuation of care

Other

This authorization only applies to records specified on this release and expires(Required)

I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment or payment or eligibility for benefits. I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of. I may revoke this authorization at any time, but I must do so in writing and submit it to the following address: Health Information Management, SHCHD, 733 Cedar Street, Garberville, CA 95542. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this Authorization. I have a right to receive a copy of this Authorization. Information disclosed pursuant to this Authorization could be redisclosed by the recipient. Such disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality law

Identification(Required)

Please upload photo of the front of your driver's license or another form of identification.

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Relationship(Required)

Self

Representative

What is your relationship to the patient?(Required)

Note: If power of attorney, SoHum Health may contact you to acquire evidence of power of attorney designation.

My signature below authorizes the release of my Protected Health Information.

Name

This field is for validation purposes and should be left unchanged.

SoHum Health

Caring for the community we’re privileged to serve^®

Release of Information

Charges for copying records