‍A valid authorization MUST contain the following information or the request will be returned:

The health and safety of our patients and staff is our highest priority. While some of these measures may pose an inconvenience, we appreciate your understanding and thank you for your assistance.

• Patient’s full name and date of birth
  (list any other names the patient may have had)
• Medical record number
  (if available)
• Specific information being requested
  (i.e., type of report/information and dates of service, etc.)
• Purpose for which the information may be disclosed
  (i.e., personal use, continuity of care, legal matter)
• To whom the information is to be sent (name and address)
• The patient’s signature or a patient’s legal representative’s signature. Authorizations signed by a representative must be verified. Please include a copy of one of the following documents indicating either:
  ‍
  - Legal guardianship papers
  - Advance Directive/Healthcare Power of Attorney (Download in English | Spanish), for patients unable to make healthcare decisions
  - Designation of Personal Representative Form (Download in English | Spanish) which allows the representative to act on the patient's behalf with regard to personal health information.
• Please note that unsigned requests will not be processed
• Date of the signature

You may contact the Shiley Medical Records office by phone at 858-534-2219.