LYG Medical Records Release Request

I authorized LYG, A Medical Corporation, to use and disclose the protected health information described below to:
Name of Healthcare Provider/Physician/Facility/Medicare Contractor (Nombre del Proveedor de Atención Médica / Médico / Centro / Contratista de Medicare)
Address of Healthcare Provider/Dirección del Proveedor de Atención Médica
Street Address Address Line 2 City State ZIP Code
Patient Name/Nombre del Paciente
First Last
Patient Phone/Teléfono del Paciente
Patient Email
Patient Date of Birth/Fecha de Nacimiento del Paciente
MM slash DD slash YYYY
This authorization for release of information covers the period of healthcare from the date of the signature or on:
Specific Date
MM slash DD slash YYYY
I authorize the release of my complete health record with the exception of the following information:
Autorizo la divulgación de mi registro de salud completo con la excepción de la siguiente información:
Medical Records to be released/Registros Médicos que se Publicarán
- Mental Health Records/Registros de Salud Mental
- Communicable Diseases (including HIV and AIDS)/Enfermedades transmisibles (incluido el VIH y el SIDA)
- Alcohol/Drug Abuse Treatment/Tratamiento de Abuso de Alcohol / Drogas
- Other (please specify)/Otro (por favor especifique)
Other Records to Release are/Otros Registros para Publicar son
Today's Date/Fecha
MM slash DD slash YYYY
Representative Name (only if applicable)/Nombre del Representante (Solo si Corresponde)
First Last

1809 E. Dyer Rd. #313
Santa Ana CA 92705

Fax (949) 975-0070

1809 E. Dyer Rd. #313
Santa Ana CA 92705

I authorize the release of my complete health record with the exception of the following information: