UniversityofSouthernCaliforniaKeckMedicine
AUTHORIZATIONTOUSEANDDISCLOSEPROTECTEDHEALTHINFORMATION
PatientInformation
Patient’sName:(last)_____________________________(first)_________________
HomeAddress:_________________________________________________________
EmailAddress:_________________________________________________________
HomePhone:_________________________DateofBirth_____________________
InformationtobedisclosedbyKeckHospitalofUSCanditsAffiliates:
DatesofService:from___________________to___________________
⬜PertinentHealthRecord(nofee,includesphysicianreportsandtestresults)
⬜SpecificInformation:____________________________________________
Locations/Providersofrecordsyouwantreleased:
❏ KeckHospital
❏ USCNorrisComprehensiveCancerCenter
❏ VerdugoHillsHospital
❏ USCCARE(PleasespecifyDoctors):
SensitiveInformation
Byapplyingachecknexttoacategoryofhighlyconfidentialinformationlistedbelow,I
specificallyauthorizetheuseand/ordisclosureofthetypeofhighlyconfidentialinformation,if
anysuchinformationwillbeusedordisclosedpursuanttothisAuthorization:
□ MentalIllness
□ DevelopmentalDisability
□ PsychotherapyNotes
□ SubstanceAbuse
□ GeneticTesting
□ Other:
□ CommunicableDisease
□ HIV/AIDSRelated
Recipient(SelectOne)
⬜EMailDelivery(Address):__________________________________________________
⬜Mail
Name:_________________________________________________________________
Address:_______________________________________________________________
⬜Pickup(IunderstandthatifIdonotpickupwithin5businessdays,thehospitalwillshred
myrecordsandImayhavetostarttheprocessagain)
Name:_______________________________________________________
TERM:ThisAuthorizationshallremainineffectforamaximumofsix(6)monthsfromthe
dateofsignature,oruntilthe__________dayof___________________,20____
PURPOSE:Iauthorizetheuseordisclosureofmyhealthinformation(includingthehighly
confidentialIselectedabove,ifany)duringthetermofthisAuthorizationforthefollowing
specificpurpose(s):Note:“attherequestofthePatient”issufficientifthePatientisinitiating
thisAuthorization:
______________________________________________________________________
I understand that once Keck Hospital of USC and its affiliates discloses my health
information to the recipient, Keck Hospital of USC and its affiliates cannot guarantee that the
recipient will not redisclose my health information to a third party. The third party may not be
required to abide by this Authorization or applicable law governing the use and disclosure of
myhealthinformation.
I understand that Keck Hospital of USC and its affiliates may, directly or indirectly, receive
remuneration from a third party in connection with the use or disclosure of my health
information.
I understand that I may at any time make a written request to Keck Hospital of USC and its
affiliates to inspect and/or obtain a copy of my health information, and that Keck Hospital of
USC and its affiliates will either, within five days for a request to inspect and fifteen days for a
request to copy, grant the request and contact me to arrange for a convenient time to inspect
and/or copy my health information or provide me with a written denial of the request that
states the basis for the denial, my review rights (if any), and instructions as to how and to  
whomImayregisteracomplaintregardingthedenial.
I understand that I may refuse to sign or may revoke (at any time) this Authorization for any
reason and that such refusal or revocation will not affect the commencement, continuation or
quality of my treatment; except, however, if my treatment is for the sole purpose of creating
health information for disclosure to the recipient identified in this Authorization, in which case
Keck Hospital of USC and its affiliates may refuse to treat me if I do not sign this
Authorization.
I understand that, at any time during which this Authorization is in effect, I may make a
written request to receive a copy of this Authorization. Such written request shall be made to
KeckHospitalofUSC’sPrivacyOfficeattheaddresslistedbelow.
I understand that this Authorization will remain in effect until the term of this Authorization
expires or I provide a written notice of revocation to Keck Hospital of USC’s Privacy Office
at the address listed below. The revocation will be effective immediately upon Keck Hospital
of USC's receipt of my written notice, except that the revocation will not have any effect on
any action taken by Keck Hospital of USC'in reliance on this Authorization before it received
mywrittennoticeofrevocation.
ImaycontactKeckHospitalofUSCat(323)4428778.
I have read and understand the terms of this Authorization and I have had an
opportunity to ask questions about the use and disclosure of my health information.
By my signature below, I hereby, knowingly and voluntarily, authorize Keck Hospital of
USCtouseordisclosemyhealthinformationinthemannerdescribedabove.
Name
Signature
Date
IfPatientisaminororisotherwiseunabletosignthisAuthorization,obtainthe
followingsignatures:
Name
SignatureofPersonalRepresentative
DescriptionofAuthority
ForInternalUseOnly
:Theidentityoftherequestorhasbeenvalidatedeitherwitha
governmentissuedpictureID,suchasadriver’slicenseorpassport,orcomparisonof
signaturesdocumentedinthePHIrecords.
___________________________________________
Signatureofemployeevalidatingidentity