I understand that the Physician may be contacted to verify and/or authorize my status as their patient as well as
any prescription and/or recommendation that could be issued to the patient. My signature on this
statement authorizes the attending Physician or CalMed 420 to make such verifications or authorization.
This signed statement shall serve as a release for this purpose only. My HIPAA rights and other
patient/physician privacy rights as detailed under California State Laws will not be violated.
I understand if the physician requests medical records, follow up appointments, or prescription
medications, it is my responsibility and obligation to fulfill my attending Physicians request.