Medical Records Disclosure Form Corona PD Case # This authorization for Use or Disclosure of Medical Information is being requested of you to comply with the terms of the confidentiality of Medical Information Act of 1981, Section 56, et seq., California Civil Code.Date MM slash DD slash YYYY Facility File Number Patient Name Birthdate Social Security Number THIS IS TO REQUEST AND AUTHORIZE:Medical Facility or Physician Address, City, State & Zip TO RELEASE MY MEDICAL, PSYCHIATRIC, ALCOHOL AND/OR DRUG ABUSE RECORDS, INCLUDING DIAGNOSTIC OR OTHER IMAGING, FOR THE FOLLOWING PURPOSE:(What the information is to be used for)RELEASE IS AUTHORIZED TO: Corona Police Department, 730 Public Safety Way, Corona, California 92878Attention I understand no further information will be disclosed until another authorization is obtained from me or unless such use or disclosure is specifically requested or permitted by law. I further understand that I have a right to receive a copy of the authorization upon my request. Copy received? Yes No Signature of Patient or Guardian Reset signature Signature locked. Reset to sign again Date/Time Witness Name and Title Date/Time Enter an email address to send a completed copy of this form to:(Required)