Anaheim, CA · Orange County
Authorization to Release Medical Information
Patients or their representatives use this form to authorize the release of specified medical information related to a fire incident.
What this form is
This form authorizes the release of specified protected health information and lets the patient or representative identify who may receive it and which records may be disclosed. It asks for patient and incident details, the authorized recipient, the records requested, contact information, and a signature. The form also requests identity documents, with different attachments listed for a minor patient.
Who needs it
A patient or patient representative seeking release of specified medical information related to a fire incident should complete and sign this form.
How to submit it
Submit the form by email to [email protected], by mail, or in person to Mindy Alvarez, 201 S. Anaheim Blvd., Suite #300, Anaheim, CA 92805.
About notarization
This document is signed without a notary; the signer just signs and dates it, and the listed identity documents are attachments, not notarized forms.
How to submit this form
- 1
Download The Form
Download the Authorization to Release Medical Information form.
- 2
Complete The Form
Enter the patient and incident details, identify the recipient and records authorized for release, and provide contact information.
- 3
Gather Identity Documents
Attach the identity document listed for the patient; for a minor, include the minor's birth certificate and the parent's or guardian's identification.
- 4
Sign And Submit
Sign and date the form, then email, mail, or deliver it in person to the contact and address listed on the form.
Frequently asked questions
- Do I need a notary for the Authorization to Release Medical Information?
- No. The form provides signature and date fields but no notary block; the signer signs and dates it. Include the identity documents listed on the form.
- What information does the form request?
- It requests patient and incident details, the person authorized to receive information, the records authorized for release, contact details, and the patient's or representative's signature.
- What attachments are required?
- Provide a copy of the patient's valid government-issued driver's license or passport. For a minor, provide the minor's birth certificate and the parent's or legal guardian's valid government-issued driver's license or identification card.
- How do I submit the Authorization to Release Medical Information?
- Email it to [email protected], or mail or deliver it in person to Mindy Alvarez at 201 S. Anaheim Blvd., Suite #300, Anaheim, CA 92805.
Need something notarized?
This Authorization to Release Medical Information doesn’t need a notary — but if you have another Anaheim form that does, a commissioned online notary can help.