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Authorization to Transfer Medical Records (California)

This form is authorization to transfer medical records in California. The form provided here is simply a sample of what the actual form looks like.


I hereby authorize ____________________________, M.D., to furnish medical information concerning

[patient's name:] ____________________________, to Dr.

[physician's name and address:] ____________________________.

Any and all information may be released, including, but not limited to, mental health records protected by the Lanterman-Petris-Short Act, drug and alcohol abuse records, and HIV test results, if any, except as specifically provided below:




[Optional:] I understand and agree to pay a reasonable charge to cover the cost the transfer. I understand the costs will be computed based on a copying fee of 25 cents per page for standard documents, actual costs for the reproduction of oversized documents or documents requiring special processing, and reasonable clerical costs for locating and making the records available.

This authorization is effective now and will remain in effect until [date:] ____________________________.

I understand that I may receive a copy of this authorization.

Signed: ____________________________

Date: ____________________________

If not signed by the patient, please indicate relationship:

____ Parent or guardian of minor patient

____ Guardian or conservator of an incompetent patient

____ Beneficiary or personal representative of deceased patient

© California Medical Association 1999
As a public service of the California Medical Association, reproduction of this document by individuals for personal use and not for commercial purposes is authorized as long as each copy clearly includes this copyright notice.

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