Health Information Management

Health Information Portability Accountability Act (HIPAA) Authorization Information

Notice: The HIPAA Authorization Form is a document required by California State and Federal Law that allows us to release records to your designated recipient. This authorization form must be completed fully and accurately. Your request will be delayed if any of the below patient information is missing:

- Patients’ Full Name & Date of Birth

- The Recipient to Whom the Records Will Be Released (Name & Address)

- The Purpose for the Release (e.g., Continuity of Care, Legal Matter, Personal Use)

- The Specific Health Information to be Released

- From specific Date: through End Date

- Disclosure Format

- The Expiration Date OF The Authorization Form

- Signature of the Patient or Legal Representative (if patient is a minor)

- A copy of your Photo ID, and/or, Supporting Legal Documentation for the patients’ representative. (e.g., Legal Guardianship, Advance Healthcare Directive/Power of Attorney, Designation of Personal Representative)

Riverside San Bernardino County Indian Health Inc. provides several options to obtain your health records. You may obtain your records via: the patient portal, encrypted email, USPS mail, or in-person.