When filling out the form, it is important to ensure that the form is completed entirely in order to process your request.
Fill out the patient information in the top section, and be sure to include a contact phone number.
Any questions regarding highly confidential information should be directed to the Release of Information staff at (714) 524-4848. This section only needs to be completed if any of the items apply and require a separate signature.
Fill in the name and address of the recipient with the name of persons or class of persons to whom Placentia-Linda Hospital can disclose your health information. Example: Dr. John Smith. Please include a phone number for the recipient.
Fill in the spaces for the term during which your authorization will remain in effect. This should be a date in the future, up to 12 months from the date of the request. Example: If you sign the form 01/12/2017, then date this section 01/12/2018.
Married people are not allowed to sign for their spouses unless they have a legal power of attorney and their spouse is incapacitated.
Adult children are not allowed to sign for a parent unless they have a legal power of attorney and the parent is incapacitated.
In general, parents must sign for all minors under the age of 18 years.
Printed and completed forms can be returned to the Placentia-Linda Hospital Medical Records Department in the following manner:
Mail the form to: Medical Records Department 1301 Rose Drive, Placentia, CA, 92870