REQUEST FOR PATIENT’S HEALTH INFORMATION

KALI S. ESWARAN M.D. Inc
1995 ZINFANDEL DR #201
RANCHO CORDOVA CA, 95670

As required by the health information portability and accountability Act of 1996 and the California law, you have a right to request the opportunity to inspect and copy health information that pertains to you. We will evaluate your request and will either grant it or explain the reason why the request will not be granted. Your right to access does not extend to information compiled in reasonable participation of or for use in a civil criminal or confidence from someone other than another health care provider.

I hereby authorize: (Name of disclosing party):

Address:

Phone:

Fax:

To be disclosed to: Kali S. Eswaran M.D. Inc
1995 Zinfandel Drive, # 201
Rancho Cordova, CA 95670.

Records and Information pertaining to:

Name:

DOB:

Address:

Signature:

Date: